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e/- 39 jj�W'� <br /> ri&Buildins Division <br /> Safe <br /> Sanitary Permit Application 8 <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> Asconsin personal information you provide may be used for secondaryMadison,WI 53707-7302 <br /> Department of Commerce [ rivacy Law,s. 15.04(1)(m)] purposes (Submit completed form to county if not <br /> state owned. <br /> Attach complete plans to the county copy only)for the s stem, n paper not less than 8-1/2 x I 1 inches in size. <br /> County Stat Sanit Permit Number ❑ eck if revision t revious application State Plan I.D.Number <br /> Qa r a <br /> I.Application Information-Please Print all Inform 'on Location: <br /> Property Owner Name Property Location <br /> u0fl 5Y- $IQbt/tt 4WI14AW1/4,S4Tg49,,N,R/S'eor <br /> Property Owner's Mailing Address Lot Number Block Number <br /> Zt 996 �; 'e a q <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> (Ju(ufh &7/t/ .SSSd3 I fr 7 4y T91 tom. <br /> II.Type of Building: (check one) ❑city <br /> OL 1 or 2 Family Dwelling-No.of Bedrooms: El <br /> lTowVillage <br /> ❑ Public/Commercial(describe use): JA t �fo� <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> Ovrrlanx ("'( <br /> A) 1. KNew System 1 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numb <br /> 3Vc3 �DS stem Tank ORl ExistingSystem D <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System:(Check all that apply) <br /> ®'Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> L Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> /So Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) // Elevation <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature( s ): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip ode) <br /> �776GI w 3S'vUC sY4rr !,l/L .i$g�i? <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing A nt gna re s s) <br /> A roved ❑Owner Given Initial Adverse Surcharge Fee) J i <br /> Determination 3�CJCJ <br /> IX.Conditions of Approval/Reasons for Disapproval:-Fled, AU34 <br /> / <br /> _ Y <br /> SBD-6398 R07/00 <br />