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SSafety&Buildings Division <br /> Sanitary Permit Application <br /> ' 1Lin <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 /> Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [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 11 inches in size. <br /> CountyState San' Permit Number ❑ eck if vision to previo application State Plan I.D.Number <br /> swPne%l� W� l3 t„ ohm 102 d� <br /> I.Application Information-Please Print all Information Location: 1�R <br /> Property Owner Name f Property Location <br /> 1 T /772.:L r, I r7 < e' 1/4 1/4,S /zT Y/N,R4X(omrW1 <br /> Property�OJwnner'r's Mailing Address y�/ / /� nn (Lot N/umber e'e:.#.� Block Number <br /> iL /C,n-J s r tire, ale- /77c&-" /CC./ <br /> City,Stam Zip Coodeel/ y� TPhone Number / Subdivision <br /> /Name or CSM Number / <br /> 3 W3, / <br /> II.Type of Building: (check one) ❑city <br /> 10 1 or 2 Family Dwelling-No.of Bedrooms: j ❑Village <br /> ❑Public/Commercial(describe use):_ aTown of <br /> ❑State-Owned 71",( Z,k <br /> Nearest Rodd y 1 <br /> Parcel Tax Number(s) -�br-,v <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A 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 0 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 /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> ?'lA <br /> VII.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 /> a ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of Itf POWTS shown on the attached plans. <br /> Plu bees Name(print) Plumbj�igna -(no p MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) _ <br /> 17Z //,5"/h S i `leder- 4 C:e_Ji r �� YYC ? t' <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin t Signa kKo stamps) <br /> IN Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination ' <br /> X.Conditions of Approval/Reasons for Disapproval: ILF <br /> 71 , <br /> i <br /> OCT 1 ? 2004 <br /> BURNE <br /> ZONNG <br /> SBD-6398(R.07/00) <br /> ------------ I <br />