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Safety&Buildings Division <br /> Sanitary Permit Application 201 W.Washington Ave. <br /> In accord with Comm 83.2 1,Wis.Adm. Code PO Box 7302 <br /> `� A See reverse side for instructions for completing this application Madison,W153707-7302 <br /> sconsin Personal information you provide may be used for secondary purposes (Submit completed form to county if not <br /> Department of commerce [privacy Law,s. 15.04(1)(m)l state owned. <br /> Attach coin fete Ians to the coon co onl f the s stem,on a er not less than 8-1/2 x 11 inches in size. <br /> County State Sani ermi Number eck i evr on to previ s application State PIrI�. Number u�er <br /> (h022 <br /> I.A Location:Application Information-Please Print all In ormation Property Location <br /> Pro rty Owner Name <br /> ' ,�1/ �/4 S�T ,N,�E o W <br /> Q� Lot Number Block Number <br /> Property Owner's Mallin Address ^7 , <br /> Ci tate �� Zip Code Phone Number Subdivision Name or CSM Number <br /> ty, j f� 0 �' /,r `s/7 d� b <br /> ri '^'` a L cJ ❑City <br /> Type of Building: (check one) ❑Village <br /> 1 or 2 Family Dwelling-No.of Bedrooms: Town of <br /> rc, <br /> Public/Commercial(describe use): s(�✓/S <br /> ❑ State-Owned Nearest -7 <br /> III,Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> to Pa�el Tax umbers) <br /> A) L New System 2. ❑Replacement 3. Tank Onlement of 4. ❑AdditionSstem 03-a C- a3o � 3 <br /> System Date Issued <br /> Permit Number <br /> B) <br /> ❑A Sanitary Permit was previousl issued <br /> IV.Type of POWT System:(Check all that apply) mound ElSand Filter ❑Constructed Wetland <br /> 0 <br /> ❑Non-pressurized In-ground ❑Single Pass ❑Drip Line <br /> ❑Pressurized In-ground Holding Tank g <br /> ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> ❑At-grade <br /> V.Dis ersal/Treatment Area Information: 7.Final <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation Elevation rade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min../inch <br /> ;2 5-0 o"z 5' l�� � <br /> Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- <br /> VI. ass Plastic <br /> Gallons Gallons Tanks Con- Con- g <br /> Information New Existing trete strutted <br /> Tanks Tanks ❑ ❑ ❑ ❑ <br /> 1 C 7g <br /> 41.Responsibility Statement <br /> I,the undersi tied,assume res ons bility for installation of the POINTS shown on the attached plans. Business Phone Number <br /> Plumber's Name(p t) Plumber's Signature(no s s): MP/MPRS No. <br /> / eAd <br /> Plumber's Address( treet,City,State,Zip Code) <br /> ex- <br /> VIII.County/Department Use Only <br /> Sanitary Pemtit Fee Includes Groundwater Date Issued Issuing gent Signature(No stamps) <br /> ❑Disapproved Surcharge Fee) <br /> Approved ❑Owner Given Initial Adverse ` 7I`Q� , IQ# <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />