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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 /> iseonsinSee reverse side for instructions for completing this application PO Box 7302 <br /> Department of Commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> (Privacy Law,s. 15.04(t)(m)] (Submit completed form to county if not <br /> Attach tom tete Tans to thecounty copy only)for the system.on paper not ess than 8-1/2 x 11 inches in size. state owned. <br /> County State Sanitary P N ber heck revisiop to revious a lication State Plan 1.D.Numb <br /> 8trnt M <br /> I.Application Information-Please Print all Inforimation Location: <br /> Property Owner Name <br /> rV► Property Location <br /> I h e/" Sw u4 W 1/4,S t1, T O,N,RLS or <br /> Property y Owner's Mailing Address } Lot Number Block Number <br /> �3 rcA5&r,e 1 7W N/A Jr$ <br /> City,State Zip Code Phone NumberSubdivision Name or CSM Number <br /> DAribtA r 5_1�930 __) f V <br /> II.Type of uilding: (check one) City <br /> V.E I or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): gTown of <br /> ❑ State-Owned C.)W '1 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road p <br /> rec�sor�e I14nat <br /> A) 1. ❑New System 2. (Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> ri VX <br /> System Tank Ord Existin S stem Ol -" 7J+S_L16— 7rV <br /> B) Permit Number Date issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ,KNon-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 /> I.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Reequired/ Proposed'i Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> Lf.S`V (Q ES 67$ r / —• gat OIL qs- -7 <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 /> -7SD l7t0 ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume res onsibili for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no tamps): Iv1P/MPRS No. Business Phone Number <br /> z2S�S1 7/s-- <br /> Rbcti. �o 66—4�S 7 <br /> Plumber's Address(Street,City,State,Zip ode) <br /> ) -7768 Yw 7s' Wytf-icY, /,ir— _;F-9r,�F3 <br /> VIII.County/Depariment Use Only <br /> ❑Disapproved Sanitary Permit Fe Includes Groundwater Date Issued Issuing nt a ps) <br /> ❑Owner Given Initial Adverse Surcharge Fee) D <br /> jijived <br /> 119 <br /> Determination _0() <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />