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x.06 oly� <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> `�seonsin 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 <br /> Department of Commerce y P Y dart'purposes Submit completed form to coon rfrrot <br /> [Privacy Law,s. 15.04(1)(m)] ( P ty i <br /> state owned. <br /> Attach complete lens to the county co only)for the s em on not 1 s than 8-1/2 x 11 inches in size. <br /> ComB.hAIr State Sanitary Permit N k' 'siogyto Ereviou a pl tion State Plan I.D.Number (� <br /> I.Application Information-Please Print all Inform tion of Location: O <br /> Pmperty Owner Name - Property Location <br /> VWCc COSMAIVO 1/4 1/4 N (or ___j <br /> Property Ownela Mailing Address Lot Number BlockdiawlWe <br /> 41, <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number L <br /> 22bq 1 S 63 - 2.q RS Il 2 . 1 <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑ Public/Commercial(describe use): (Town of <br /> ❑ State-Owned usk <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. New System 1 2. ❑Replacement 3. ❑Replacement of 14. ❑Addition to Parcel Tb <br /> System Tank OnlyExistingS stem <br /> B) Permit Number Date Issued <br /> 13A Sanitary Permit was previouslyissued <br /> 13!.Type of POWT System:(Check all that apply) <br /> pNon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> O Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> L.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application S.Percolation Rate 6.System Elevation 7.Final Grade <br /> y Required Proposed Rate(GalsJday/sq.ft.) (Min./inch) Elevation <br /> V1.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 /> 6g 1 ka►� ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> Vit.Responsibility Statement <br /> I,the undersigned,assume res nsibili for installation of the POWTS shown on the attached plans. <br /> Plumbels Name(prin/t --II Plumber/'s Signature no ): MP/MPRS No. {- Business Phone Number <br /> (' <br /> �GI♦�} II�PWNS (NSASSJ IS' ' `C1J7 <br /> umbels Address(Street,Ci ,Stete,Zip ode) <br /> N). 1148 <br /> VIII.County/Departmenf Use Only <br /> ❑Disapproved I Sanitary Permit Fee(Includes Groundwater Date Issued Issuing A at SiM& ps) <br /> afxpp ved 13 Owner Given Initial Adverse Surcharge Fee) ! /7�� <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />