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Sanitary Permit Application Safety&Buildings Division <br /> S In accord with Comm 83.2 1,Wis.Adm. Code 201 W Washington <br /> Box Ave. <br /> 7302 <br /> ,`4sconsin See reverse side for instructions for completing this application <br /> Personal information you provide may be used for secondary purposes Madison, to county 7302 <br /> if <br /> S <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county n 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 11 inches in size. <br /> County State Sanitary Permit Nu er ❑ het f vise toprevious ap lication State Plan 1.D.Num e <br /> ca ,�rl oc5(v10 <br /> I.Application Information-Please Print all Inforrhation Location: <br /> Pro ny er Name t Property Location <br /> P7 / 6 <br /> �`_ <_ Ko/") 5 1/4 1/4,S I7 T� ,N,R E or <br /> Property Owner's Mailing Address k �aiAlwnlaec Block Number <br /> a,�, L 4,1L)/o1j.) 7-,pr/'Ace <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> e Grn e MA)- �^ 3 <br /> II.Type of Building: (check one) ❑City <br /> W— 1 or 2 Family Dwelling-No.of Bedrooms: ❑village <br /> ❑ Public/Commercial(describe use): 04own of <br /> ❑ State-Owned ,77 e e-,-uD _2 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest ltoadJ p,ss cl <br /> Q l <br /> A) 1. ❑New System 2. O,Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) •t <br /> System Tank Only Existin S stem 3 3/ 6 7 o U <br /> B) Permit Num ' <br /> Date Iss ed / <br /> A SanitaryPermit was reviousl issued a7 l iO <br /> IV..Type of POWT System:(Check all that apply) <br /> NNon-pressurized In-ground ❑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 /> 4/5-0d'I 7..:2 o 17h 3 -- ID —9y 7oC <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 strutted <br /> Tanks Tanks <br /> S �,c 006> 00o0 ❑ ❑ ❑ ❑ <br /> um <br /> dD ❑ ❑ ❑ ❑ <br /> Vfl.Responsibility Statement <br /> I,the undersigned,assume res onsibili for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) // Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> G u�f/a��l �✓a.� 0Z2769/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 13 Cp X S/ Sart e P <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit F ncludes Groundwater Date I ued Issuing A n ign a <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) / <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />