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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 /> See reverse side for instructions for completing this application PO Box 7302 <br /> iseonsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department or Commerce [Privacy Law,s. 13.04(1)(m)] (Submit completed form to county if not <br /> state owned. <br /> Attach complete plans to the county copy only)for the system,on paper not less than 8-I/2 x l 1 inches in size. <br /> CountyY C State Sanitary 't ❑Chce if revision to a plication State Plan I.D.Number <br /> I.Application Information-Please Print all Info6nation Location: <br /> Property Owner Name , Property Location <br /> IJ (or) <br /> /l (� <br /> l(' fiur tj NPI1/4 Wwl/4 S 3yTit Rr E or W/ w <br /> Property Owners Mailing Addre s Lot Number Block Number <br /> Z <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> W,PbOer- U/.L Srf�9� "1/5' 866- 0105 <br /> II.Type of Building: (check one) ❑City <br /> Q& 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑ PublietCommercial(describe use): 2 Town of //�� <br /> ❑ State-Owned 61 lXkthl' <br /> M.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Ne�*5�t Road R A <br /> r�,e+r Cit <br /> A) 1. [$New System 1 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tate Number(s) <br /> System Tank Only Existing System Od'0 tr 3 3 e l c( r CIO <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System:(Check all that apply) <br /> 14 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 S.Percolation Rate 6.System Elevation 7.Final Grade <br /> SO Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> /04.3 /a4�g ,? - 9Ss `f q71 <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 /> /000 /U <br /> / ❑ ❑ ❑ ❑ <br /> crwesr+0 <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I the undersigned,assume res ibility for installation of the POWTS shown on the attached plans. <br /> Plumbers Name(print) Plumber's Signature(nostain ): MP/MPRS No. Business Phone Number <br /> 'psWane be6ACO/M /.1),t� a_2 341— 7OL$6 <br /> Plumbers Address(Street,City,State,Zip Code) <br /> _ c <br /> —25 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permitee(Includes Groundwater Date Is ued Issuing Sign ps) <br /> pproved ❑Owner Given Initial Adverse Surcharge F <br /> ce <br /> P� I Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />