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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 /> `�seonsin Se reverse side for instructions for completing this application PO Box 7302 <br /> Department or Commerce Perso information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned. <br /> )� Attach tom fete to the coon co only)forthe systemon a rot less than 8-1/2 x I I inches in size. <br /> Cof n <br /> unty (3(-t Y n Q lf7r Shu Sk i n to ious plication State Plan I.D.Numbw_J vO1 <br /> 01-ZT'lac <br /> L A "Cation Information-Please P int a Information Location: (� <br /> Property G/�wner Name <br /> 7� / Property Location �/ I <br /> Pie-h4#4 N / ��L`'2'S/•f ! �Q s50 fiL/ Nr Il4 ��t/4 S J4 T c7 N,RfSE or <br /> Property Owner's Mailing Address <br /> Lot Number Block Number <br /> City,State T—ZipCodc Phone Number Subdivision Name or CSM Number <br /> web.SfYY W- 3__� g3 Its— £fbh �f987 13snrlrrGL� Eh v,/3 , 4S <br /> II.Type of Building: (check one) ❑city <br /> 13 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑ Public/Commercial(describe use): ATown of <br /> ❑ State-Owned JAC/C fOh <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> w✓ L& /� <br /> A) 1. l!1 New System 2. ❑Repla ement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numbers) <br /> S stem Tank Onlv Existing S stem 6 fj, <br /> B) Permit Number Date Issue <br /> ❑A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System:(Check all that apply) <br /> (H Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Welland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Inform tion: <br /> 1.Design Flow(gpd) 2.Dispersal Ares 3.Dispersal Area E!7fffk.) S.Percolation Rate 6.System Elevation 7.Final Grede <br /> Required Proposed (Min./inch) Elevation <br /> 6413 (W -- q3, 1 <br /> �s <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existinj trete strutted <br /> Tanks Tanks <br /> /L906 ❑ ❑ ❑ ❑ y� <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I tbe undersigned assume res 'bill installation of the POWTS shown on the attached lana. <br /> Plumber's Name(print) PlumbeesSignature( ): MP/MFRS No. Business Phone Number <br /> Wa.el.e /Ju hdlen ,2��9� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> h0. /4 <br /> VIII.County/Department Use Only <br /> FDetcrmi!u2tion isapproved Sanitary P it Fee(Includes G ndwater Date I ued Issuing Si o <br /> '�7Approved wniven Initial Adverse Surcharge F n <br /> �t tJ <br /> IX.Conditions of Approval/Reasons I or Disapproval: <br /> SBD-6398 807/00 <br />