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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 /> Visconsin See reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not SU <br /> 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 /> County State Sanitary Permit Number ❑Check if revision to pre ' us application State Plan 1.D.Number 98/43,/ <br /> Qv 4571 T <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location O) <br /> k,S ,{ Se 114&i4AA,S2 T 3 7N,R E(or, <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 69 " � //„ jOrt'vee0 � rp <br /> City,State Zip Code TPh,-one Number Subdivision Name or CSM Number <br /> II.Type of Building: (check one) ❑city <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ UrTown of <br /> ❑State-Owned de- <br /> Nearest <br /> eNearest Road n <br /> ,Si, 1Q/. e <br /> Parcel ax Nu ber _ /_ CT-_ <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. ❑Replacement 3. V Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date 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 ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment 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 /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> VII.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 /> /W� / 4l•�SPf L.c�n GTP <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> PP461 <br /> ber's Name(pntr <br /> Plumber's Signa re stamps): MP/MPRS No. Business Phone Number <br /> .4P / O✓( 11� <� �3�6 5 /s Ccs S� zslA21 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin en gnatu stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination �O� A/1c, { 24,Orf <br /> X.Conditions of Approval <br /> aoy, Aq(ACEatm.J'C o>•uL--Y. Extsr,* STret- �aroics t4AV rm(- p /Yoo, 03. <br /> SBD-6398(R.07/00) <br />