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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> ` ISCOnsin See reverse side for instructions for completing this application 15 Box 7302 <br /> Personal information you provide may be used for secondary purposes Madison, to county 7302 <br /> Department of commerce [Privacy Law,s.15.04(1)(m)l (Submit completed form to county if not <br /> state owned. <br /> Attach complete plans to the county copy only)for system,on paper nmQt less than 8-1/2 x 1 I inches in size. <br /> County C.I�N State Sani P umber ❑ if rcyisio r�v�ous plication Stale Plan I.D.Number v '� <br /> f-- -Fag <br /> o <br /> I.Application Information-Please Print all Information Location: 1 <br /> Property Owner Name D Property Location 7 y/ �) <br /> Alu e- �� Gr IMAJ�/4 Sl J-7OraN l"4E or 1` <br /> Property Owner's Mailing <br /> /Address _ J Lot Number Block Number <br /> AJ, I�/ <br /> Ci t is Zip Code Phone Number Subdivision Name-or CSM Number <br /> ,f/v 4-1,e o— -5�o 8 2- <br /> II.Type of Building: (check one) ❑arty <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> �3r f o of <br /> ❑ Public/Cormnercial(describe use): <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest RoaG 70 e"' <br /> A) I. New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax N s) <br /> S stem Tank Onl -ExistingSystem A O U 0 <br /> B) Permit Number Date Issued <br /> 13A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System:(Check all that apply) <br /> Yon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> L.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Arra 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(GalaJday/sq.R) (Min./i=ch) Elevation <br /> 6v3 6Y� F111 / 9 <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> -c l�iG DDd 11Dv a�wcscv <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> 1,the undersigned,assume res ibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Signature starnpa: No. <br /> Plumber's Name(print) MP/MPRS Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee cludes Groundwater Date Iss Issuing i s) <br /> AAarovea ❑Owner Given Initial Adverse Surcharge Fee) Q� T�\ �✓ZG 6 j A <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07M <br /> r- <br />