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Safety&Buildings Division <br /> Sanitary Permit Application 201 W.Washington Ave. <br /> In accord with Comm 83.21,W is.Adm. Code PO Box 7302 <br /> Visconsin <br /> See reverse side for instructions for completing this applicationMadison,WI 53707-7302 Personal information you provide may be used for secondary purposes (Submit completed form to county if not <br /> Department of commerce [Privacy Law,s. 15.04(1)(m)] 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 /> State S ►t Number eck i r v�s�on to reviou plication State Plan I.D.Number <br /> County IY�/OVI <br /> Location: <br /> I.App ication Information-Please Print all Information Property Location <br /> property owner Name 1/4, 1/4,S I T <br /> 1.t S ` �� — Lot Number Block Number <br /> Property Owner's Mailing Address1 ' ( 0 V t/ ( <br /> 3� S 4-rb" "^ Phone Number Subdivision Name or CS Number <br /> City,State Zip Code <br /> hlizrl'n.e o►isf, (M1')f 5�6 ( ) —536 ❑city <br /> II.Type of Building: (ch k one) ❑Village <br /> 0 1 or 2 Family Dwelling-No.of Bedrooms: 19Town of <br /> Public/Commercial(describe use):_ <br /> ❑State-Owned Nearest Road <br /> ti r s o_% Lit, Pd <br /> Parcel TaxNumber(s)O2,, q 1 _p O <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) 5 6. ❑Addition to <br /> A) 1. ❑New 2. P&Replacement J. ❑Replacement of 4. Existing System <br /> System System Tank Only Date Issued <br /> Permit Number <br /> B) ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> 1$Non-pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑Pressurized In-ground ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> ❑At-grade <br /> V.Dispersal/Treatment Area Information: <br /> 2.Dis ersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation Elevation GradeFinal <br /> 1.Design Flow(gpd) 2. wired Proposed Rate(Gals./day/sq.ft.) (Min./inch) <br /> Required <br /> Soo gzC1 tfgs <br /> Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> VII.Tank Con- Con- glass <br /> Information Gallons Gallons Tanks crete structed <br /> New Existing <br /> Tanks Tanks ❑ ❑ ❑ ❑ <br /> S� � 7So WIe <br /> CIo ❑ 0 ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS show��PReSatt ched plans. Business Phone Number <br /> Plumber's Name(print) PI tuber's Signatu (no ps): 7K p 6:-- O <br /> N.els ,e Y- r ZZS 22 (�(O (j C1 <br /> Plumber's Address(Street ity,State,Zip Code) i <br /> �' `f S t✓� 2 1,t1 e�s Y <br /> IX.County/Department Use Only Issum ent Signature(No stamps) <br /> ❑Disapproved SanitaryPermit Fef(Includes Groundwater Date Issued <br /> Approved O Owner Given Initial Adverse Surcharge Fee) <br /> W O'C1(J� lJ <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R 07/00) <br />