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11 <br /> Misconsin <br /> SanitaPermit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code <br /> See reverse side for instructions for completing this application y p may used for ma 201 W.Washington Ave. <br /> Department of commerce Personal information you Provide bsecond l 5 Box 7302 <br /> secondary purposes Madison,WI 53707-7302 <br /> (Privacy Law,s. 15.04 1 m <br /> ( )( )I (Submit completed form to county if not <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x 1 I inches in size. state owned.) <br /> County State Sanitary Pemi t ber <br /> 4�N Che k if siop,to revious ap ication State Plan I.D.Number <br /> I.Application Information-Please Print all I ormation # <br /> Property Owner Name Location: <br /> Property Location <br /> Property owners ailing Address IVC-11A 7/4,S T-7%,N,R/'E <br /> �� Lot Number (or <br /> O Lc>p Q�, Block Number <br /> City,Sta Zip Code e -- <br /> Phone Number Subdivision Name or CSM Number <br /> I .Type of Buildin check one) ( >63�' Yq' /Sti9dclj� {+p <br /> g ( 3 � �i / a/C <br /> I 1 or 2 Family Dwelling-No.of Bedrooms: ❑CttY S4 <br /> ❑Public/Commercial(describe use):_ ❑Village <br /> Town of <br /> 13 State-Owned <br /> 4 <br /> Nearest Road <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Parcel Taxes ber(s) <br /> a 8 qV <br /> A) 1. ew 2. ❑Replacement J. ❑Replacement of q. <br /> System System Tank Only 5. 6. ❑Addition to <br /> B) <br /> ❑A SanitaryPermit Number Existing System <br /> Permit was previously issued Date Issued <br /> Z-Type of POWT System: (Check all that apply) <br /> on-pressurized In-ground <br /> Pressurized In-ground ❑Mound ❑Sand Filter <br /> ❑At-grade ❑Holding Tank ❑Constructed Wetland <br /> ❑Single Pass ❑Drip Line <br /> ❑Aerobic Treatment Unit 13 Recirculating 11 Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area <br /> Required Pro o ed 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> P Rate(Gals./day/sq,ft.) (Min./inch) <br /> 75 0 e y� 3 Elevation <br /> VII.Tank ��� T— <br /> Capacity in Total #of �'S' 9- �5' q ��3- ��j <br /> Information Gallons Manufacturer Prefab Site Steel Fiber- Plastic <br /> Gallons Tanks <br /> New Existing Con- Con- glass <br /> Tanks Tanks crete structed <br /> IF-' /I Odd — Do J ° ° - <br /> Em crefe ° <br /> VIII.Responsibility Statement <br /> ° ❑ ❑ ❑ ❑ <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's <br /> /t Name,((print) / / Plumber's Signature(n stains :e 4 1V FSS+ P) MP/MPRS No. <br /> Business Phone Number <br /> Plumbers Address(Street City,State,Zip Code) Rt�c ��Z7� <br /> elpx s! S�� e <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary <br /> pproved ❑Owner Given Initial Adverse Surcharge Permit F e(Includes Groundwater Date Issued <br /> _ )� Issuing Agent Signature ps) <br /> Determination x� <br /> X.Conditions of Approval/Reasons for Disapproval: Cl <br /> i13D-6398(R.07/00) <br />