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-&gam do 3,4? �`` <br /> Sanitary Permit Application a e Buildings Divisiot <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave <br /> NviSCOnSin See reverse side for instructions for completing this application PO Box 730: <br /> Personal information you provide may be used for secondarypurposes Madison,WI 53707-730: <br /> Department or Commerce P y P coup f no <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county i <br /> state owned. <br /> Attach com tete lans to the countyco only)for the system,on paper not less than 8-1/2 x I 1 inches in size. <br /> County ATF State Sanitary Permit Number ❑Check if revision to previous application State Plan I.D.Number 6 ZZ <br /> I.A ication Information-Please Print all Information Location: 3 <br /> Property Owner Name <br /> /��^�' ,�y+ Property Location <br /> &ANOTProperty Owner's Mailing Address ' GDv , Mvraa RE 1/4 SE1/4,S T N, E or 15 <br /> Lot Number Block Numb <br /> 141O60 - AV s� n2 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> _Sjgjgd 1-.11 I 540o-72- 1 i 5 -ZI 38 <br /> II.Type of Building: (check one) ❑City <br /> ❑ I or 2 Family Dwelling-No.of Beto�o�m�s: ❑Village <br /> Public/Commercial(describe use): ,nL.�jFA_YX�l,_,_r WjW -�j own of <br /> ❑ State-Owned AIWVPN <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road An. nn <br /> A) 1. ❑New System 1 2.replacement 3. ❑Replacement of 4. ❑Addition to P ce Tax Numbers) <br /> S stem Tank Onl Existing System -33 -43- <br /> B) Permit Number Date Issued <br /> A Sanitary Permit was previously issued I 3agoZS - _g 'l Say &1 <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground ❑Mound ❑ Sand Filter ❑Constructed Wetland <br /> ressurized In-ground ❑ Holding Tank ❑Single Pass ❑ Drip Line <br /> ❑At- de Aerobic Treatment Unit ❑ Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> I.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) 93,$ Elevationg,g <br /> 4-504) 5600 4016 � a -q3,$ 17.4 <br /> VI.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 /> SEp(jc Ptz"� !no <br /> 10 5150 I) ?40 4 W lE� ElC1 ❑ ❑ <br /> 1SC,S 15105 1 1 <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) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> uAAW .✓ - ?ZSBS/ <br /> umbers Address(Street,City State,Zip Code) <br /> 2-7160 35, w8am 6JI- -54$93 <br /> VIII. County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee{Includes Groundwater Date Is ued IssuingrAjeSigna e o ps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) 7(x( 1 ©0 0 o <br /> Determination (Ju <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />