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One"j, <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> 41sconsin See reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for secondary Madison,WI 53707-7302 It <br /> Department of Commerce Y P Y rypurposes -ip <br /> [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 I inches in size. <br /> County to SaniPer jilt Number ❑ eck if revision ttoopprevious application State Plan I.D.Number <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name / fr Property Location <br /> A�er'.CY, 4 ^„ fir` /p��c!/� 1/4 1/4 5 T 3 7N R/& or <br /> )40 <br /> Property Owner's Mailing Address Lot Number Block Number <br /> /0791­ S ,'r,'7t ���e JPd o/ Z <br /> Ci ,State Zip Code Phone Number Subdivision Name or CSM Number <br /> S�v tv 7 c9 ya e�? �g'9-Z9z9 <br /> II.Type of Building: (check one) ❑City <br /> Jit 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): Town of <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest oad <br /> A) 1. ❑New System 2. JKReplacernent 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Only ExistingS stem O 3 Y-1,5.6 O �� <br /> B) Permit Number Date Issued <br /> [IA 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 IK 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 /> Sno Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks ,,� / <br /> �( 36,0 / w,'�Se r ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(pri Plum Signatu (no ps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 3✓f 12 /J!: <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin gent Signature(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surchar FGe) / , <br /> Determination // (5 <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />