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077 _��450 <br /> ' Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> N isconsin See reverse side for instructions for completing this application PO Box 7302 <br /> Department of commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> Attach com Tete Tans to the coon co onl for the system,on paver not less than 8-1/2 x 11 inches in size. state owned. <br /> Count State Sanitary Permit Number ❑ k if revision to re us application State PI D umber <br /> UQ <br /> I.ApPlication Information-Please Print all Information Location: <br /> Property Owner Name <br /> /1 nR <br /> Property Location <br /> Property Ownerailing Address (V 1/4 1/4,S T ,N E o <br /> Lot Number Block Numb <br /> �53 UCHAWA/s/ ST r/.� . 3 <br /> City,State Zi Code <br /> Zip Phone Number <br /> Subdivision Name or CSM Number <br /> V 16 <br /> II.Type of Building: (check one) ,pq 13 <br /> ❑city <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑ Public/Commercial(describe use): Town 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 <br /> umnd <br /> A) 1. New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parc T N mbe s <br /> System Tank Onl ExistingSystem ,� �"Qt Z <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.Dis ersalffreatmeat 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) <br /> Elevation <br /> S 1 .o `�— q7.s q 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 crete structed <br /> Tanks Tanks <br /> low ❑ ❑ ❑ ❑ <br /> VV ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersi ed,assume res onsibili for installation of the POWTS shown on the attachedplans. <br /> Plumber's Name(print) Plumber's Signature no s ps): MP/MPRS No. <br /> :;Ie Number <br /> icl{Rxco /� s r 2Z.�'SSl i <br /> Numbers Address(Street,City,State,Zip de) `7 <br /> 2-7760 14 13s (,J/ . .C.893 <br /> VIII.County/Department Use my <br /> ❑Disapproved Sanitary Permit Fee(In lodes Groundwater Date Issued Issuing t Si lure stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination �O(> �f—,Z-7- Ot) <br /> X. dations of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />