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Sanitary Permit Application Safety&,L rfflft <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washingto ve. <br /> `�seonsin See reverse side for instructions for completing this application PO BdT" M <br /> Department or Commerce Personal information you provide may be used for secondary purposes Madison,WI 53707 <br /> [Privacy Law,s. (5.04(I)(m)] (Submit completed form to cou <br /> stat <br /> Attach complete plans to the countyco only)for the s s ,on a er not les than 8-1/2 x l I inches in size. <br /> County State Sanitary Pe i N m e ❑C e if 'sion�r us a ' <br /> lica on State Plan I.D.Number <br /> I.A ication Information-Please Print all I fo ma io t� Location: <br /> Property Own`e�rf1-1 N�ame Property Location <br /> 1/4 1/4,S 33T t,N,R/� or <br /> Property wnePs ilio Address Lot Number Block Number <br /> 4 � � <br /> ate Zip Codc Phone Number Subdivision Name or CSM Number <br /> A4 I W . .SS/v ( 61-L 327- CSM V, 3 0, 3 . _. <br /> II.Type of uilding: (check one) /ry ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): TTS 2WTown of <br /> ❑ State-Owned 1 44&" 7Vlo <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road iy „_ <br /> re <br /> A) 1. / dew System 2. Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Nummbbgr(s)) <br /> System Tank Only Existing System ozo 03 g00 <br /> B) <br /> El Permit Number Date Issued <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 /> ❑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 /> 1/f//�VJ�/,O Required Propo ed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> i-�� 3. 9( - $ <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 strutted <br /> Tanks Tanks <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumbers Name(print) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> AkA—w .✓ ?2585/ S - IS7 <br /> umbers Address(Street,City State,Zip Co e) <br /> 2.7760 35- W'5aM Wi• -54$g3 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit F e(Includes Groundwater Date sued Issuing Age Si mps) <br /> pproved ❑Owner Given Initial Adverse Surcharge e) � <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapp oval 1 <br /> �ts4..ca:7� J5QIfLt? 5wef-(kr "P. 30 CH & a <br /> SBD-6398 R07/00 a <br /> y <br />