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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 93.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> ` 1sconsinSee reverse side for instructions for completing this application PO Box 7302 <br /> Department of Commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> [Privacy Law,s. 15.04(1)(m)) (Submit completed form to country if not (� <br /> state owriod.) <br /> Attach complete plans to the county copy only)for the system,on=not less than 8-1/2 x l 1 inches in size. V I <br /> County State Sggi 't umber heckTiTtion to previ application State Plan I.D.Number <br /> 3 sr�(pif <br /> I.Appfication Information-Please Print all Information Location: <br /> Property Owner Name Property oc <br /> rty Lation //// <br /> aw <br /> Property eras Mailing A I/4 1/4 SL ,N W <br /> Lot Number Block Num <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> yRR Aid I 1j4C <br /> Type of Building: (check one) ❑city <br /> 1 or 2 Family Dwelling-No.of Bedrooms:�-- ❑Village <br /> ❑ Public/Commercial(describe use): R7'own of D yt ►/r rr, /V <br /> [3 State-Owned A�t�r'IIV <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road lAaoz , a i- <br /> A) 1. ❑New System 2.�lteplacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Num s) Ll� <br /> S stem Tank On( Existing System <br /> B) Permit Number to Issued <br /> LOA SanitaryPermit was previous issued <br /> V Type of POWT System:(Check all that apply) <br /> on-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground D 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 /> quired Proposed Rate(GalsJday/sq.ft.) (Min./inch) Elevation <br /> 3� 432 . 7 9s .(A 19S .C) <br /> VI.Tank Capacity inTotal #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Galion Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> Isco <br /> VII.Responsibility Statement <br /> I,the undersigned,assume Eesponsibilitv for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumbe2s Signature(n ): <br /> 2MP/MPRS No. Business Phone Number <br /> Ic�iat20 1�av�u>;ls t4�uttd 252'► 7lS- $(a6- 467 <br /> Plumber's Address(Street,City,State,Zip C ) <br /> 2-'7 760 , t� lal� .54� 3 <br /> VIII.County/Department U Only <br /> ❑Disapproved Sanitary Perrin ee(Includes water Date Is Issuing As t 'gnamre o <br /> Approved ❑Owner Given Initial Adverse Surcharge Foe <br /> Determination ��CC <br /> IX.Conditions of Approval/Reasons for Disapproval: It It <br /> SBD-6398 R07/00 <br />