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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 /> See reverse side for instructions for completing this application PO Box 7302 <br /> *5co' n-sin <br /> Personal information you provide may be used for secondary purposes Madison,W153707-7302 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x I 1 inches in size. <br /> County . State Sanitary Permit Number ❑Check if revision to previous application State Plan 1.D.Number <br /> 31-IIPne4 1 4JJ 5-79C) <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> 'ckoT 1 Gm lar-� SE 1/41VO I/4,S S-T41e,N,R/�Y(or <br /> Property Owner's/JMailing Address Lot Number Block Number <br /> p,33 Yf `7 y <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 0j'JU , mly 1 Ss�B 145-1 ) ?70-6 9 eST Vr I P. 63 (CIL a � <br /> II.Type of Building: (check one) ❑City <br /> Rl I or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> Town of <br /> ❑Public/Commercial(describe use):_ <br /> ❑ State-Owned <br /> Nearest Road <br /> Parcel Tax Number(s) <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) 7 <br /> A) I I. N New 2. ❑Replacement 3. G Replacement of 4. 5. 6. ❑Addition to <br /> _System System Tank Only Existing System <br /> B) I Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> � <br /> .Type of PONT System: (Check all that apply) <br /> Non-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 /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.Syste Elevation 7.Final(ttade <br /> -3 J j — W�;7rr Required Proposed Rate(Galslday/sq.ft.) (Min./imch) .3_ q3 0 leva[i <br /> k � -3�S°w s6a.S� 573 6T< -y 3 - ;g0.6 ° /_ I S; <br /> VII.Tank Capacity in "i oral #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks i <br /> 70 52) <br /> I1(Il tC(!t� ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> I <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Pium is Name(print) Plumber' Signature(no stamps: MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street City,S te,Zip ode) <br /> IAI 9W9 Ll d 2�90 <br /> IX.County/Depariment Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuir ent Signa (No stamps) <br /> ED Approved ❑Owner Given Initial Adverse Surcharge Fee) ��� <br /> Determination PYoU <br /> X.Conditions of Approval <br /> It(IS 5y51-6M D651&-) /S f;4. A o2 66012COM 4U,56 WITH 3 P�rsv�l GGG�rr� y t1F <br /> ��5 G9ct�rtvs/ shy P�alc FLOW. <br /> SBD-6398(R.07/00) <br />