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Safety&Buildings Di <br /> Sanitary Permit Application 201 W.Washingto <br /> In accord with Comm 83.21,Wis.Adm. Code PO Bo <br /> `�sconsin See reverse side for instructions for completing this application Madison,WI 5370 2 <br /> Personal information you provide may be used for secondary purposes (Submit completed form to county <br /> Department of Commerce (privacy Law,s. 15.040)(m)] <br /> state o <br /> Attach com lete plans to the coon co onl for the s s m,on a er of less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Pe mb r eck i ision to , 'o application State Plan 1.D.Number <br /> I.A ication Information-Please Print all I rmatton Location: <br /> Property Owner Name t Property LZ ion <br /> y) 30)Z E �K /�/ /4 <br /> /c��J KY Lot Number Block Number' <br /> Property Owner's Mailing Address <br /> S190 q1 Subdivision Name or CSM Number <br /> City,State Zip Code Phone Number <br /> ,� S4g3o s6- b <br /> dwi <br /> vim <br /> ❑City <br /> II.Type of Building: (check one) i'/ ❑Village <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: !/ own of <br /> ❑ Public/Commercial(describe use): ass <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> Parcel Tax N er(s <br /> LB) <br /> 1. New System 2. ❑Replacement 3. ❑Replacement of 4. El Addition to � �y'� l 6) ,,/c� <br /> System Tank Onl ExistingSystem. J G <br /> PermitNumber Date Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> .Type of POWT System:(Check all that apply) ❑Sand Filter ❑Constructed Wetland <br /> Non-pressurized In-ground ❑Mound <br /> ❑ ressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: 7.Final <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application L(5�4pin <br /> tion Rate 6.System Elevation Elevation <br /> rade <br /> Required Proposed Rate(Gals./day/sq.ft.) ) ' <br /> 00D� . X7. 5 <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Ftlass Plastic <br /> Information Gallons Gallons Tanks Con- Con- g <br /> New Existing Crete structed <br /> Tanks Tanks <br /> / L13 SSC) <br /> 13 ❑ ❑ <br /> c Sbo Soo <br /> VII.Responsibility Statement <br /> I,the undersigned,assume res onsibili for installation of the POWTS shown on the attached plans. Business Phone Number <br /> Plumber's Name(print) Plumber's Signature(no stamps): MP/MPRS No. <br /> umber's Address(Street,City State,Zip Co e) <br /> 2-7760 �jS �n1£135T loll. 54893 <br /> VIII.County/Department Use Only <br /> hW <br /> ❑Disapproved Sanitary Permit (Includes Groundwater Dat I�ue 6?_� Issuing ge Si atu tamps) <br /> roved ❑Owner Given Initial Adverse Surcharge F <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />