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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> iseonsin See reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for secondary purposes Madison, to county if <br /> ` <br /> 7302 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not 1 <br /> state owned. <br /> Attach compfete plans to the county copy only)for the sysion,on paper not lessthan 8-1/2 x I 1 inches in size. <br /> County State Sanitary Perm, Num hoc if 'Sion vious appl,ca On State Plan I.D.Number 13� <br /> u/fU <br /> I.Application Information-Please Print all JWrfiIAojj Location: <br /> (Owner Name p ,p Property Location <br /> Pro r / <br /> A 4 ` `• 1/4 1/4 S�/ T3 4�N R E or W <br /> Property Owners Mailing Address Lot Number Block Number <br /> E <br /> 377y �► X0 e �, <br /> City,Stater / Zip Code Phone Number " n Name or CSM Number <br /> o C-e ✓// e- w s � s 7�s 3a-��aV17 OQ144 -A-1 6 <br /> / <br /> II.type of Building: (check one) ❑city <br /> `iL 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Publie/Commereial(describe use): j-Town of/ <br /> ❑ State-Owned h /4 O//e, e <br /> Ill.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> e ref C C r^ <br /> A) 1. $.New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax N r(s) <br /> System Tank Only Existing S stem C,/ o2;?O O.S' S <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued <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.Dis ersal Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 1 3.Dispersal Area 4.Soil Application S.Percolation Rate 6.System Etc on .Final Grade <br /> vsa <br /> R/equired Proposed Rate(GaWday/sq.ft.) (Min./inch) ovation C� v3 aO , 6397�7 . 7 <br /> VI.Tank Capacity inTotal #of Manufacturer Prefab Site Steel 'Fiber- Plastic <br /> Information <br /> Of <br /> Gallons Tanks Con- Con- glass <br /> New Existing crete suucted <br /> // Tanks Tanks <br /> 5* rr C 4000 t— 0 U t? p,/cr/cSC O ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> 1,the undersigned,assume resnsibili for installation of the POWTS shown on the attached plans. <br /> Plumbers Name(prin Plumber's Signature stamps). MP/MPRS No. Business Phone Number <br /> le <br /> Plumm�bees Address(Street,City,State,Zip Code) <br /> f N S—� //'� KJ G✓ S , <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit FM(Includes Groundwater Date I ued Junin A t Signature(No s <br /> P)roved E03Owner Given Initial Adverse Surcharge Fee Q1 41 <br /> Detemtination I ' <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 807/00 <br />