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Safety&Buildings Division <br /> Sanitary Permit Application 201 W. Washington Ave. <br /> In accord with Comm 83.21. Wis. Adm. Code PO Box 7302 <br /> `�5ebn5%n See reverse side for instructions for completing this application Madison.WI 53707-7302 <br /> Personal information you provide may be used for secondary,purposes (Submit completed form to county if not <br /> Department of commerce (Privacy Law.s. 15.04(I)(m)] state owned.) <br /> Attach complete plans(to the county copy onh•)for he system.on a er not less than 8-1/2 I I inches in size. <br /> County State Sanitary t t Nwnber ❑ heck if r vision to previous plication State Planl.D.Number <br /> k .-c � <br /> I. Application Information- Please Print all Information Location: <br /> Property Owner Na/me / Property Lo lion <br /> 41/4 I/4,S/3 T3 ,N,R� or <br /> Property Owner's Mailing Address Lot Number Block Number cam,) <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> J <br /> II Type of Building: (check one) ❑City <br /> I or 2 Family Dwelling—No.of Bedrooms:_ ❑village <br /> Town of <br /> ❑ Public/Commercial(describe use): <br /> ❑ State-owned ��''� <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Ne rest Road <br /> 0O N, d <br /> A) L )CNew System 2. ❑ Replacement 3. ❑ Replacement of 4. ❑Addition to Parcel Tar mber(s) <br /> System Tank Only Existin S stem <br /> B) Permit Number Date Issued <br /> A Sanitary Permit was previousl •issued L68'5 <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground 3-,'c/C w; df ti ❑Holding Tank ❑Single Pass ❑Drip Line l <br /> ❑At-grad ❑Aerobic Treatment Unit. ❑Recirculating ROthe <br /> id - dD,f,L,Tf c y r-e-�, 3A, <br /> V Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.DispersalArea 1 3.Dispersal Area 4.Soil Application S.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq ft.) (Min./inch) Elevation <br /> 9 9 9� 99. s' <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 /> p Tanks Tanks �] ) <br /> �r vG X !4d ! 3—/1d4✓ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII Responsibility Statement <br /> I the undersigned,assume responsibility for installation ofthe POWTS shown on tached plans <br /> Qmber's Name(pr'nt) Plumber's Signature(no stamps): MP PRS o. Business Phone Number <br /> ad� 4 �,-Jt„s <br /> uinbefs Address(Street, State,Zip e) <br /> lGl oZ d h o 8J j <br /> VIII County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing A ent Signatur (No ) <br /> ppr ed ❑Owner Given Initial Adverse Surcharge Fee' <br /> Determination 7� <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />