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Sanitary Permit Application Safety&Buildings Division <br /> Washington Ave. <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W. PO Box 7302 <br /> Visconsin <br /> See reverse side for instructions for completing this application 5 Box 7 Personal information you provide may be used for secondary purposes Madison,WI 302 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned.) J <br /> Attach complete plans(to the county copy only)fopiffie system,on paper not less than 8-1/2 x 11 inches in size. <br /> CountyY ! / State Sanitaryer it umber ❑ h ck if gvisiioon t previdPlan State 1..D.Number <br /> I.Application Information-Please Print all Information Location: <br /> Pro etry Owner Name Property Location r �j <br /> c-(— C:),5;., �1/4 Al q14,S ( T T 1,N, (or)W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> A " , w ; S 4g30 ( les ) 6S0-361 <br /> II.Type of Building: (check one) , / ❑City <br /> lir 1 or 2 Family Dwelling-No.of Bedrooms: `i ❑Village <br /> ❑Public/Commercial(describe use):_ Town of <br /> ❑State-Owned (S L4,, C S S <br /> Nsgest Road <br /> `/4rl4S /�Jfb <br /> Parcel Tax umber(s) <br /> 2- 0(-01 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. KReplacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Datelssued <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 ❑Holding Tank ❑Single Pass ❑Drip Line <br /> KAt-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.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 I _ crete structed <br /> Tanks Tanks �y IBO <br /> 11 13 El <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(printI Plu is Signature(n ps): MP/MPRS No. Business Phone Numberr <br /> (S *erV lzS2 7�� �b <br /> Pluthbees Address(Street,City,State, ip Code <br /> 7S SCJ�` Sdxr3 <br /> IX.County/Department Use Ghly <br /> ���� ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issui Age ignatu stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> VI} 1 R�` 674 <br /> Determination ly ° (l <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />