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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> N*seonsirn See reverse side for instructions for completing this application 15 Box 7302 <br /> Personal information you provide may be used for secondary purposes Madison, to county if <br /> 7302 <br /> Department of Commerce (Privacy Law,s.15.04(l)(m)] (Submit completed forth to county if not <br /> state owned. I h <br /> Attach complete plans to the county copy only)for the system,<rn paper not 1 8-1/2 x 11 inches in size. 1, <br /> County State Sanitary Permit NurpVj 1 revi ? top v s a/ppliciu n State Plan I.D.Number <br /> I.A ation Information-Please Print all Information t 0 �F Location: <br /> Property Owner Name Property Location <br /> 1/4 1/4 S7 ,N E W <br /> P tTvncrs Mailing Address Lot Number Block Num <br /> :2A005W.V.R. <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> -VAiJ I 154930 IS Ver Q-4 Ks Type of ding: (check one) U city <br /> E3 e <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 3 XTowngof <br /> ❑ Public/Commercial(describe use): DA�'p�p <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Neareaw <br /> A) 1. IoNew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to ParceS stem Tank Onl Existin S stemS�01 . 02 <br /> B) 1 Permit Number Date Issued <br /> ❑A Sanitary Permit was previouslyissued <br /> IV.Type of POWT System:(Check all that apply) <br /> )gNon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-wade ❑Aerobic Treatment Unit ❑Rccirculating ❑Other. <br /> V.Dis ersaUTreatment 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 /> Re 'red Proposed Rate(GalsJday/sq.ft.) (Min./inch) Elevation <br /> �43 4S I .'7 196.3 qa- <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 ryy� <br /> ❑ El ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I the undersi ed assume res nsibili for installation of the POWTS shown on the attached lans. <br /> Plumber's Name(print) Plumber's Signature(n s s): MP/MPRS No. Business Phone Number <br /> PI beta Address(Street,(.ity,State,zip C e) <br /> OW1. _eAg <br /> VIII.County/Depart ent Use Only <br /> 1-0—Disapproved Sanitary Permit (Includes G�ror((ndwater Date Issued [suing /1"17Signe e) <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee) a i /�// �( <br /> vv Determination V <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07M <br />