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1 r <br /> Safety&Buildings Division <br /> Sanitary Permit Application 201 W.Washington Avc. <br /> In accord with Comm 83.21.Wis.Adm. Code PO Box 7302 <br /> See reverse side for instructions for completing this application Madison.WI 53707-7302 <br /> Visconsin personal information you provide maybe used for secorldan Purposes (Submit completed form to county it mol <br /> Department of Commerce (privacy Law.s. 15.04(Ixm)] <br /> state owned.) <br /> Attach Com tete la's(to[he count'•co •only)for the ssteta on not less than 8-1/2 a I I inches in size. <br /> County ${ate_San' Permit Number ❑ -if revisiaa w �s�pliation Sate Plan 1.D.Number <br /> 71 <br /> 1. Application Information-Please <br /> ✓✓/ZP•"int all Information �S Location' — p <br /> Property Owner Nome Pte?'Location tj1�1 <br /> or 5414 S/b T ,N. or <br /> Lot Number Hbtk Number <br /> property ownefs Mailing Address <br /> 2 o Co iPoad ti <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 6-49r3 ( '`JiS ) 3y,.-z <br /> o city <br /> II Type of Building: (check one) 17 Village <br /> lir I or 2 Family Dwelling-No.of Bedrooms: 51'tawn of <br /> ❑ Public/Commercial(describe use) / <br /> O State-owned <br /> 1.1.1 T)pe of Pc:reit: (Check tim)y one box on line A. Chcck boa on line B if applicable) <br /> A) 1. ❑New System 2. C(Replacanent 3. O Replacement of 4. O Addition to Parcel T r Nutt�eCr((s) <br /> S stem Tank Only Existin S em Q� �2 <br /> B) PerIssued <br /> mit Number Dae <br /> ❑A SanitaryPermit was reviousl•issued <br /> IV.Type of POWT System:(Check all that apply) pd Filter ❑Constructed Wetland <br /> ❑Non-pressurized In-ground O Mound <br /> A Pressurized In-ground O Holding Tank O Single Pass ❑Drip Line <br /> O Al-gradeO opruobbi1c Treatment Unit ❑Recirculating O Other: <br /> //14-/0 )eon ,Qevussars <br /> V Dis rsallPnematut t Area Information: <br /> 1.Design Flow(gpd) 2.DispasidArea 3.Dispersal Ara F4.Soil 5:Percdaliorr Rue 6-Systern jo¢. 7.Final Grade <br /> Required Proposed ft) (Minfatch) T-3 Elevation <br /> 7 s 37S 3g9 t� / /e Zs <br /> VI Tank Capacity in Total R of Manulfactuer Prefab Site Stecl Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing Crete strueted <br /> Tanks Tanks <br /> pEEC) <br /> ( 06 ❑ ❑ ❑ <br /> VII Responsibility Statement <br /> I,the tnrdersi assume nsibili for installation of the POWTS shown on dw attat9tod 11ms. Business Phone Number <br /> Plum erne( ) Plumber's ( ) MPAAMS No- <br /> e� r�SOh <br /> Plumbers A�dtdress(Suet[,City,state,Zip code) _e / <br /> e ti <br /> ss� <br /> VIII County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Dae Issued 1 A" Si (No stamps) <br /> Approved O Owner Given Initial Adverse Surcharge Fee) Qct /O 6 M — <br /> Determination �'U <br /> IX.Conditions of Approval/Reasons for Disapproval: <br />