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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 93.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> `01 sconsinSee reverse side for instructions for completing this application PO Box 7302 <br /> Department of Commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> (Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> Attach complete plans to the coon co onl for the s stem on a paper t less than 8-1/2 x l 1 inches in size. state owned. <br /> County Q ti r h f - State Sanitary P 't bar if reyssion previous plication State Plan t.D.Number`\ <br /> I.A lication Information-Please Print Infor atlon Location: <br /> Property Owner Name �4- Properly Location _ <br /> J.)DY/Q/l `Jw 1/4 S 3 T�IQ IS J <br /> Property Owners Mailing Address 1/4 6V N R B or <br /> Lot Number Block Number <br /> llow W, -- <br /> City,State Zip Code Phone Number Subdivision N or CSM Number <br /> Websfrr� wr s� r3 cif - 4sG3 <br /> II.Type of Building: (check one) ❑City <br /> ,61 I m2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑ Publie/Conuncreial(describe use): 13f Town of <br /> ❑ State-Owned 0ev-1em <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> S h„e- /Lc( <br /> A) 1. ($New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numbers) <br /> System Tank OnlyExistingSystem ; <br /> ? o O a� <br /> B) <br /> Permit Number r Dale issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> &LNon-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.Dis ersal/7 reatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation7.Final Grade <br /> Rcgwmd Proposed Rate(GalsJday/s9.R) (Mindinch) Elevation <br /> du yss— <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 stmeted <br /> Tanks Tanks <br /> S e t,� /ooe i000 /t/o I-Wes C u- ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I the undem'Ped assume res ibility for installation of the POWTS shown on the attached plans. <br /> Plumbers Name(print) Piumber�tura o stamps): MP/MPRS No. Business phone Number. <br /> a-s Flo/M �76J 7/S-349- ��g6 <br /> Plum rs Address(Street,City,State,Zip Code) <br /> 0 /3oX -' S/rrvl W_�7- <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fx�nr�aGrmmweter Data as O Issuing Si _(fV s) <br /> PProved ❑Owner Given Initial Adverse Su itary Permit <br /> t S6r/(// Gam/ <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br /> Olt l <br />