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Ji nc" <br /> Safety&Buildings Division <br /> Sanitary Permit Application 201 W.Washington Ave. <br /> In accord with Comm 83.21,Wis.Adm. Code p0 Box 7302 <br /> `�seonsfn See reverse side for instructions for completing this application Madison,WI 53707-7302 <br /> Personal information you provide may be used for secondary purposes (Submit completed form to county if not Q <br /> Department or commerce LPrivacy Law,s.15.04(1)(m)] state owned. }� <br /> e. <br /> Attach complete lana to the coup co only)for s stem on a r not 1 8-1/2Sts a 11 inches.p. u beer <br /> Stele Sani P 't ❑C 'f revi�ign to mvi licah n State I. Number <br /> C4W`y rne�t' ��` Location: <br /> I.Application Information-Please Print all of rmHon aProperty Location <br /> property Owner Name 1` ,,- / <br /> s+'eve �a>ti Lem W 1/4 N w <br /> Lot Number Block Number <br /> property Owners Mailing Ad� �� . <br /> �a r✓st� <br /> Zi ode Phone Number Subdivision Name or CSM Number <br /> city,state p O -rX 9 <br /> ❑city <br /> II.Type of Buildin . ( heck one) E3 Village <br /> I <br /> 1 or 2 Family Dwelling-No.of Bedrooms: )9 Town7of <br /> ❑ Public/Commercial(describe use): t.(/OD <br /> ❑ State-Owned re�c,�a <br /> d <br /> M.Type of Permit: (Check only one box on line A. Check box on line B if applicable) e�{�r p !A }yo <br /> ^r Parcel Tax Numbers) <br /> A) 1. WNew System 2. ❑Replacement 3. ❑❑anReplacement <br /> k On ement of 4. ❑xAd�Addition tem — 33D�ao1 � <br /> System Date Issued <br /> Permit Number <br /> B) <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) '.Mound ❑Sand Filter ❑Constructed Wetland <br /> ElNon_presaurized In-ground ❑Holdin Tank ❑Single Pass ❑Drip Line <br /> ❑Pressurized In-ground g <br /> El At- a ❑Aerobic Treatment Unit ❑Recirculating ❑Other <br /> V.Dis ersaVl7reatment Area Information: 7. <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4 Se(GelpsJdry/soq R) (Mi5. n%n�)n m 6.System Elevation El�le+vation rade <br /> Required proposed nc / !/ C/ ! . <br /> Z{SD q� qS� I 7 <br /> V1.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Gallons Gallons Tanks Con- Con- glass <br /> Information <br /> New Existing crete strutted <br /> Tanks Tanks ❑ ❑ ❑ ❑ <br /> SO 12f'r�- ❑ ❑ ❑ O <br /> &-'M 12 <br /> V11.Responsibility Statement <br /> I the undersigned,assume res 'bili for installation of the POWTS shown on the attached lana. Business phone <br /> Number <br /> Plumber's Name 'nt) Pl s Signature(no WIMP"No. <br /> (S r ZZ n' ir�(o6 Ok <br /> Plumber's Address Stat,City, tate,Zip Code) <br /> V j � t 7 67 <br /> VIII.County/Department Use O y <br /> ❑Disapproved <br /> Sanitary Permri ce(Includes Groundwater Date sued Issuing Si ) <br /> pproved ❑Owner Given Initial Adverse Sege F Mot <br /> Determination �Z <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07100 77 <br /> SEPI <br /> Sup Zoo/ �l <br /> 'Zoiv��c)N7-�, <br />