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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> VI&Sconsin See reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> Ccu��ty• State Sanitary Permit Number ❑ e^ck if revision to previous application State Plan I.D.Number <br /> Lit//"N , <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name / J r pl fy Location�r e_A,n G e/�d /1/4$E 1/4,s3 T39,N,RryE(o W <br /> Property Owner's Mai' g Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> G�.�- sou r w. sY 2 c ) -sy7 <br /> Il.Type of Buildi g: (check one) ❑City <br /> Pr- I or 2 Family Dwelling-No.of Bedrooms: �❑Village <br /> ❑Public/Commercial(describe use):_ 0TOwn of <br /> ❑ State-Owned �i /yJ /' fj/iyn�rJ <br /> Nearest#oad <br /> 0 <br /> Parcel T umber(s _ 3 ._,�-C,0 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) 94 - <br /> A) I. ❑New 2. ❑Replacement 3. ❑Replacement of 4. < 5. 6. ❑Addition to <br /> System System Tank Only �eui � Existing System <br /> B) Permit Number Date Issued <br /> Sanitary Permit was previously issued 7 -o C01"' 41—a <br /> IV.Type of POWT System: (Check all that apply) <br /> "P 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 /> 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) Elevation <br /> 5--2:; G y3 e ? �— <br /> VII.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 /> 6D0 Ov ❑ ❑ ❑ ❑ <br /> II.Res1ponsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(prin Plumber's Signatureno stamps): MP/MPRS No. Business Phone Number <br /> ZAlfi ea <br /> Plumber's Address(Street,City,State,Zip Code) <br /> tZoXS-/ S/i^ � . w77 87Z <br /> IX.County/Department Use Only <br /> ❑Disapproved Sai iitry-Permitfcc(Includes Groundwater [DateIssuedIss ' Agent S' nature(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) ',,ll _ r <br /> Determination �o2S//U v 03 Az <br /> A-- <br /> X.Conditions of Approval/Reasons for Disapproval: w --'- I <br /> U J—J�v I <br /> APR 2 9 2003 <br /> SBD-6398(R.07/00) ZONING <br />