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Safety&Buildings Division <br /> Sanitary Permit Application <br /> 201 W.Washington Ave. <br /> In accord with Comm 83.2 1,Wis.Adm. Code PO Box 7302 <br /> ` 1SCOnSin Seereverse side for instructions for completing this application Madison,WI 53707-7302 <br /> Department of Commerce Personal information you provide may be used for secondary purposes (Submit completed form to county if not <br /> [Privacy Law,s. 15.04(1)(m)] 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 SanitaryPermit Number ❑Check ifrev'i silonn ttoo pr ious application State Plan I.D.Number <br /> 3'13 <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name ,',t Property Location <br /> (r Go t^ e W n n Nw l/4 5E- 1/4,S Ll T V,N,R 1k or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> h1 PLS m N. 5 G tJ. 791-- 3/3 7 6W -q d'eLa Ke_ <br /> Il.Type of Building: (check one) ❑city <br /> 30 Village <br /> k& I or 2 Family Dwelling-No.of Bedrooms: Town of <br /> ❑ Public/Commercial(describe use): Q�le la a <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Roa a� <br /> �a d rri G <br /> A) 1. A New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Nu er(s) <br /> System Tank Only Existing System I <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System: (Check all that apply) <br /> �[Non-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(GalsJday/sq.It.) (Min./inch) Elevation <br /> ��o G 3 It& 4qr 4+ 9r il <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume res on ibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no tamp): MP/MPRS No. Business Phone Number <br /> 1 �y S7 7i5= o6;umber —? <br /> Q1 <br /> Plumber's Address(Street,City,State,Zip de) <br /> .-7760 I.1�4-y, 3S We/ kr{,'e- WZ- S7,893 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fle6Includes Groundwater Date Issued Issuing A t Sign ps) <br /> 1pproved ❑Owner Given Initial Adverse Surcharge Fee) re �� �j� /Q /� <br /> V Determination �{� c ` ✓ 0 A 41 <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />