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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 /> `visconsinSee 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 �J <br /> state owned. ' �`� <br /> Attach complate Plans to the county cony only)for P system,on paper BQt less than 8-1/2 x l 1 inches in size, lJ <br /> �Wty State Sanitwy Permit N her D 2r if reyfsion to previous lication State Plan I.D.Numb <br /> I.A lication Information-Please Print a aformation Location: <br /> Properly Owner Name <br /> Property Location <br /> PrIC. i SCAF{- p^ '' <br /> Gl/4 Ll/4 S/ T NRI or W <br /> Owner's Mailing Address Lot Number Block Number <br /> 33► I-el m#4 S+ idt I <br /> City,state Zip Code Phone Number Subdivision Name or CSM Number <br /> •-41V C/a„e wi, I S t/70 f 7/S b''3S- ?43 CSfn V 13 F Yo <br /> II.Type of Building: (check one) ❑City <br /> K I or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑ Public/Commercial(describe use): Town of <br /> ❑ State-Owned i e f s <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) N crest d �iPvt d: <br /> A) 1. ❑New System 2. PrReplacement 1 3. ❑Replacement of 4. ❑Addition toParcel Tax Num,�s) <br /> S stem Tank Onl Existin S stem QO y` 6-4- YD0 <br /> B) Permit Number Date Issued <br /> ❑A Sari Permit 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 1A Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-"e ❑Aerobic Treatment Unit ❑Recirculating ❑Other. <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Am 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(GalsJday/sq.R.) (Min./inch) Elevation <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 structed <br /> Tanks Tanks <br /> I�! X Zt�00 I13D ❑ ❑ <br /> 1 eSea <br /> VII.Responsibility Statement <br /> I the undersip assume re ibili for installation of the POWTS shown on the attached plans. <br /> Plumber's Name cent) Pl bet's Signature o stamps): MP/MPRS No. Business Phone Number <br /> t°ls ICOer r U4 klx� 7/S 6- 40k' <br /> Plumber's Address(street,City,State,Zip Code). <br /> C_e�� ( PSS r tvt' S is <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit (Includes Groundwater Date Issued Issuin rot Si re ) <br /> 6Pp�ved ❑Owner Given Initial Adverse Surcharge Fce) e .` O I <br /> tVJ <br /> Determination /� <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br /> CpUN / <br /> N� <br />