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Sanitary Permit Application Safety&Buildings Division <br /> s In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 � 1 <br /> `t sc gnsfn Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 X <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed forth to county if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x 1 I inches in size. <br /> County State Sanitary Permit umber ❑Check if ' ion t previous appli tion State Plan I.D.Number r <br /> 2�3at J6 <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> t <br /> er r 1/4 1/4,SaYTy ,N,R/E(or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 7/5-0 C c.C, ..3 7 ex. V.3&-a P. <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> k b w f' w x s v 3 U > (��6-3a s�(bd� l'�on AJ1/J %{ Sec, as <br /> II.Type of ilding: (check one) ❑City <br /> ❑, 1 or 2 Family Dwelling-No.of Bedrooms: 11 village <br /> \iiPublic/Commercial(describe use):_ y? 5' 10e -� it1 y� own of <br /> l <br /> ❑State-Owned 5W/$S <br /> Nearest Road _ <br /> Parcel Number(s) <br /> 11I.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. w 2. ❑Replacement 3. ❑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 ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground M1 olding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade �[jj 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 crete strutted <br /> Tanks Tanks <br /> A�v/rJ,�; ��o — a;p o �.4 w ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(p' t) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> BOA :s--/y s e,A,) t,✓� S-y�7� <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent Signature(No stamps) <br /> ApprovedElOwner Given Initial Adverse Surcharge Fee) <br /> Determination 111 <br /> X.Conditions of Approval/Reasons forPisapproval: t� ,1 /U / / <br /> su�j,c`f �. G�11�Z�5 p � �j2 d�ul'i���T �. Sl`�n�TarA and, <br /> e /J , l /'3 ,'1/�><1 `�aarr,eou�il/�J}-' ��S> �s S <br /> s / C <br /> e� -hs l ta,?� � ret4Ar�l <br /> SBD-6398(R.07/00) <br />