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y s DivisionSafet &Buil in <br /> • Sanitary Permit Application g <br /> 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 <br /> N iseonsinpersonal information you provide may be used fur secondan purposes Madison.WI 53707-7302 <br /> Department of commerce <br /> [Privacy Law.s. 15.04(1)(m)I (Submit completed form to county if not <br /> state owned.) <br /> Attach comptete plans(to the county co only) fo he system,on a r not less than 8-1/2 x I I inches in size. <br /> County Stat 'ant a P tit N�ryvber ❑ heck if r visigr tr�.previ us application State Plan I. D.Number <br /> CNE , : � <br /> ) 2.el 9 <br /> 1. Application Information - Please Print all Information Location: t <br /> Pro erty Owner Name _ Property Location <br /> / /'l <br /> ` /dY. 1/4 S'L. 114,SLO T sO,N.R/E(o& <br /> Property Owner's Mailing Addres Lot Number Block Number <br /> 0 s 9 �s tf�,. Qv c N• L / / <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> v, i/J j E d ellen/ ��.ee <br /> J14 � � ri�� 1 ��� ) y�/r8v Y <br /> 11 Type of Building: (check one) ❑City <br /> Air I or 2 Family Dwelling—No.of Bedrooms .3 ❑Village <br /> ❑ Public/Commercial(describe use): ,Town of <br /> ❑ State-owned 0C' <br /> III Type of Perm. (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> c <br /> A) I. ❑New System 2. Replacement 3. ❑ Replacement of 4. ❑Addition to Parcel Tar Number(s) <br /> `stem Tank Existing System (IZd — 9 80 =d3 /60 <br /> B) Permit Number Date Issued <br /> ❑ A Sanitary Permit was previously issued <br /> IV,'I'ype of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground ❑ Mound ❑ Sand Filter ❑Constructed Welland <br /> ❑Pressurized In-ground W loIding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V Dis ersaVrreatment Area Information: <br /> I.Design Flow(gpd) 2.DispersalArea 3.Dispersal Area 4.Soil Application 5.Percolation Rale 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq R.) (Min./inch) Elevation <br /> YSo — <br /> VI Tank Capacity in Total 4 of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> T.✓K X dee./d Z d� ❑ ❑ ❑ ❑ <br /> VIl Responsibility Statement <br /> 1,the undcrsi ned,assume responsibility for installation of the POWTS shown on t chcd plans, <br /> umber's Name(print) Plumber's Signature(no stamps): MP/ PR Business Phone Number <br /> dw :,t,s - 7—g7z Y7Z - JPYVS, <br /> PI tuber' Address(Sheet,Cit),State,Zip ) <br /> v_r ' a r, /,tcc 10,J JY �s 3 <br /> VIII County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin Ag i Si ps) <br /> _t <br /> pproved 11Owner Given Initial Adverse Surcharge Fee) <br /> Determination I // ✓/ ` t�/` <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />