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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 /> isconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [Privacy Law, s. 1 be us d f or (Submit completed form to county if not <br /> state owned. <br /> Attach complete plans(to the county copy only)for the system,,on papersystem,, not less than 8-1/2 x 11 inches in size. <br /> CountyState Sanitary Permit Numb eck if revi o to previous ap licati State Plan 1.D.Number ! <br /> AIA <br /> �u n e /t �l <br /> I.Application Information-Please Print all Information Location: C <br /> Prop y Owner Name / Property Location 6 <br /> Q/0 /I e—S e--V 1/4 5411/4,S 7, T_*Se ,N,R/�E or Cx <br /> Property Owner's Mailing Address le Lot Number Block Number <br /> City,State Zip Code Te Number Subdivision Name or CSM Number <br /> Gd ��e�� " /,.� S_'Yo )ALG-2, -� <br /> II Type of Building: (check one) ❑City <br /> X I or 2 Family Dwelling—No.of Bedrooms: ❑village <br /> ❑ Public/Commercial(describe use): 41 Town of <br /> ❑ State-owned <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Neares °t Road <br /> � t <br /> A) 1. J4.New System 2. ❑Replacement 3. ❑ Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Only Existing System 016 3 oz Q -7- eZOU <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> 32�Non-pressurized In-ground ❑Mound ❑Sand Filter D Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade D Aerobic Treatment Unit ❑Recirculating O Other: <br /> V Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.DispersalArea 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation T.Final Grade <br /> 366 RequiredProposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 14ky e43 t7 gs, � q-7, -T <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 /> )Vd I u/Cse 0 /&'W <br /> D ❑ ❑ ❑ ❑ <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) Plumb is Signatur no tamps): MP/MPRS No. Business Phone Number <br /> Fs40 6 � �7� 9j -7/s 31iy _-7a416 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 1c S/ <br /> VIII County/Department Use Only <br /> ElDisapproved Sanitary Permit Fee(Includes Groundwater Date sued Issuing Age 'Si ur s ps) <br /> Approved D Owner Given Initial Adverse Surcharge Fee) 61) <br /> Determination V061Q <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> Soy m� <br /> .6398(R.07/00) <br />