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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 /> "MrsevnsinSee reverse side for instructions for completing this application PO Box 7302 <br /> Department or commerce Personal information you provide may be used for secondary purposes Madison,WI 53707.7302 <br /> [Privacy Law,s. 15.04(I)(m)) (Submit completed form to county if not <br /> state owned. <br /> Attach complete lams to the county copy only)for the system,on paper not less than 8-1/2 x l I inches in size. <br /> count State Sant it er ❑ h k if revj�ion to pre your a plication State Plan L D. be <br /> urn a Sd <br /> 1. Application Information-Please Print all Information Location: <br /> Property Owner Name e Property Location <br /> Qr C4tS�rKQ �Q ( W (� pO �j �(jf <br /> r r` Y`� �'� "`' 1/4�r-r/I/4 S�"uTJ�N R1 o W <br /> Property O cYs Meiling Address <br /> Lot Number Block Number <br /> �. 3 .150 s- (.c)�!�«Jnr d . J <br /> City,State Zip Code phone Number <br /> � 6 YD Subdivision Name or CSM Number <br /> G rG k4s it.r 7/S Y' v S7 <br /> 11. Type of Building: (check one) ❑City <br /> ,K 1 or 2 Family Dwelling-No.of Bedrooms : ❑Village ` <br /> ❑ Public/Commercial(describe use): Town of <br /> ❑ State-Owned 00S 19 it r- <br /> lIi. Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearyst+RoadW I' I t4 klig <br /> A) I ❑ New System 1 2. X Replacement 1 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank OntExistin System <br /> 40-0 of '7C30 <br /> B) Permit Number Datc Issued <br /> ❑ A Sanitary Permit was previously issued <br /> IV. Type of POWT System: (Check all that apply) <br /> ❑ Non-pressurized In-ground 0 Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑ Pressurized In-ground Q Holding Tank ❑Single Pass ❑Drip Line <br /> Q AL-grade ❑ Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V. Dispersal/Treatment Arca 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.n.) (Min./inch) Elevation <br /> 6°O 600 6©g / `` ?7. ? 99. 7 <br /> VL 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 /> Qd C IS ❑ ❑ Q ❑ <br /> !o Gv P,FP f� <br /> c r X ILS/ WI�rPY C1 ❑ ❑ <br /> VII. Responsibility Statement <br /> I,the undersigned,asswne res onsibi t for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) P mbers Signat re(n tamps): MP/MPRS No, Business Phone Number <br /> Ale S �� t�� 22 �2 Z 71T A � 6 oto <br /> lumber's Ad(dr�ess(Sire/a/,�,C�i y,State, ip Code) /\) W p�/J/ ,yl� - <br /> VIII. County/Department Use Only <br /> ❑ Disapproved Sanitary Pcinn ee(Includes Groundwater D�e ssued Issuing A ent Sig tyre mps) <br /> T.4pproved ❑Owner Given Ini[ial Adverse Surcharge Fe (q/j// <br /> !� Determination -t,� v I <br /> Ili. Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/W <br /> � �� 3 <br />