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Ckv <br /> ' Sanitary Permit Application Safety&Buildings <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washingt <br /> ` iseonsin See reverse side for instructions for completing this application PO B <br /> Department of Commerce Personal information you provide may be used for secondary purposes Madison,WI 537 <br /> [Privacy Law,s. 15.04(t)(m)] (Submit completed forth to coon <br /> Attach tom le[e tans to the coup co onl )for s stem,on a er n less than 8-t/2 x 1 l inches in size. state o e <br /> County State Sanitary P it b ❑C if revision previ lication State Plan 1.D.Number <br /> v tMr@ f� #OOCC �- <br /> I.Application Information-Please Print 1 InformationLocation: <br /> Property Owner Name <br /> (70 <br /> / �r I/q/� Property Location <br /> Property Owners Mailing Address l/4 1/4,S SST OX RAE or <br /> Lot Number at <br /> lIOZO 6lPsv Ir.f�� / ,� 3 <br /> City,State Zip Code Phone Number <br /> Subdivision Name or CSM Number <br /> II.Type o Building: (check one) ❑City <br /> X I or 2 Family Dwelling-No.of Bedrooms:— ❑Village <br /> C1Public/Commercial(describe use): J!TTown of <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road//) SDS <br /> A) L /leA)r U/ <br /> New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numb r(s) <br /> System Tank OnlyExistin S stem Z d/ / <br /> B) Permit Number Date Issued <br /> C3 SanitaryPermit was reviousl issued <br /> IV.Type of POWT System: (Check all that apply) <br /> XNon-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 atment 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.) (MinJinch) Elevation <br /> �15b 6 6Y 7 612e yc� <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 /> I <br /> l'J — /G�p ❑ ❑ ❑ I ❑ Ind <br /> VII. Responsibility Statement <br /> I.the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumbers Name(print) Plumbers Signature(no stamps): MP/MPRs No. <br /> Business Phone Number <br /> WO gAjl ►: 'A 2 zs'8SlQ� <br /> Plumber's Address(Street,City,State,Zip Ude) S_ W6– J c <br /> 2-7760 14.,v3r E W . X4893 <br /> VIII.County/Departme t Use Only <br /> ❑ Disapproved Sanitary Permit Fee( eludes Groundwater Date Iued Issuing Age oigl/,aire <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) god . <br /> q . <br /> Determination U <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07100 <br />