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3 9©q <br /> Sanitary Permit Application Safety&Buildings Di <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washingto <br /> Aseonsin See reverse side for instructions for completing this application 15 Bo. 02 <br /> Personal information you provide may be used for secondary purposes Madison,WI 53707 <br /> Department of Commerce (Privacy Law,s. 15.04(t)(m)] (Submit completed form to coup n <br /> state o <br /> Attach complete plans to the county copy only)forAc system.oniner not less than 8-1/2 x 11 inches in size. <br /> County 'I r State Sanit e Nu�er ❑ h k i revision to r ious application State Plan L D.Number <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property LocationaOl / <br /> � 1/4 1/4,Sf T41 ,N,Rt�E or <br /> Property owner's Mailing Address Lot Number --9+ack-h'aff Eer <br /> 116621 6 rouse j(Jw 4.1- 3 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> C46AZoids Ato LT 4 y y63 )7167-IN <br /> II.Type of Building: (check one) ❑City <br /> 19 1 or 2 Family Dwelling-No.of Bedrooms: 2 ❑village <br /> ❑ Public/Commercial(describe use): Town of <br /> ❑ State-Owned �5 W t`$ <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest RoIN ad drP.B/' <br /> lk <br /> A) 1. p New System 2. ❑Replacement 3. ❑Replacement of 4. ❑ Addition to Parcel ax Nags) <br /> 2B) System Tank OnlyExistingSystem 57J7— 02- <br /> B) <br /> Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT 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.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> -00 yZC X682 .7 1 9Z-15 9ZZ-Y <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel I Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> 0 Cl 0 C3 <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumbers Signature(no stamps): bIP/MPRS No. Business Phone Number <br /> ,f n ZZS8S1 Is g66- S <br /> Pl mbees Address(Scree,City,State,Zip C de) <br /> 7-? bo 1_ '51-3 9-7 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit (Includes 6t.Qundwater Date Iss ed Issu�in ent Si ps) <br /> Lroved I ❑Owner Given Initial Adverse Surcharge Fee`' �(^JCJ\ <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 807'00 <br />