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Safety 8c Buildings Division <br /> Sanitary Permit Application 201 W.Washington Ave. <br /> _u—+r In accord with Comm 83.21,Wis.Adm. Code PO Box 7302 <br /> Madison,WI 53707-7302 <br /> oerrartme t o n Personal information you provide may be used for secondary purposes (Submit completed form to county if not <br /> (Privacy Law,s.15.04(1)(m)) state owned <br /> Attach complete plans to the county copy only)forthe system,on paper not less than 8-1/2 x I 1 inches in size. <br /> CountyURNL Soft Sanitary P umber ❑ 'sicn previousannReseim State Plan L D.Number <br /> I.Application Information-Please Print all Inf rmation Location: <br /> Ply Owner Name Pmputy Loranon <br /> Property ow s < 6 )/a ` 1/4,,S/ T 3r� 61 e <br /> Maddig Morris Lott Numberr BlBb ock Number <br /> a4p X75 4 E7H 44/--�' R0 <br /> City,State Zip Cade Phone Number Subdivision Name or CSM Number. <br /> S oNLsYL �l 175 ) G�SS.�/S Csh7 ✓-tel Pa�/� <br /> R Type of Buildin : (check one) . ❑ r y <br /> ty <br /> O city <br /> I or 2 Family Dwelling-No.of Bedrooms: lw <br /> �own� <br /> ❑ Public/Commacial(describe use): <br /> ❑ State-owned <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) N sd D <br /> ..0 i G5t T7 <br /> A) 1. ❑New System 2. XRepW=ent 3. ❑Replacement of 1 4. ❑Addition to Parcel Tax Numbet(s) <br /> System Tank Only Existin S stem o a L(- 31(73 -o(fl <br /> B) Permit Number Date Issued <br /> Sari Permit was previouslyissued <br /> IV.Type of POWT System:(Check all that apply) <br /> ❑Non-pressurized In-ground /1/2 Rac-< ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized la•gmund ❑holding Tank ❑Single Paas ❑Drip Lia <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other. <br /> V Dis nal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.DispetsalArm 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Fine/ <br /> Requited Proposed Rate(��day/s4 R) (Min./inch) Elevation <br /> yso 1/36 I-le -- 97=Z'' 99 -Z)1 <br /> VI Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New I Existing Crete ahncted <br /> Tanks Tanks <br /> 14000 /QDd P4000-e-7 ❑ ❑ ❑ ❑ <br /> C3 a — <br /> VII Responsibility Statement <br /> I,the undersi ed,assume respo ibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Nate(print) Plumtan MP/MFRS No. Busims Phone Number <br /> 1319b 4-/) L:( -f)QUtlrc1' o�a(oC970 <br /> -Plumber's Add=(Strut,City,State,Zip Code) VV <br /> /4, 7/ -�) S . S�AYC Rig 3s l�til� t.vi - 830 <br /> VIII County/Department Use Only <br /> ❑Disapproved Sanitary Pump Fee�udes Gm mdwater Date Issued <br /> ved C3 Owner Given Initial Adverse Sumhvge Fee) lasumg <br /> Determination / �'�® / �6-iQ'O <br /> VL Conditions of Approval/Reasons for Disapproval: <br />