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Sanitary Permit Application Safety&Buildings Division <br /> Visconsin <br /> PerIn accord with Comm 83.21,Wis.Adm. Code 201 W W shington Ave. <br /> p0 Box 7302 <br /> See reverse side for instructions for completing this application <br /> Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned.) 31) <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. 31) <br /> County State Sgnitary�eprrit ryher ❑C k if rev'sion to previous a lication State Plan I.D.Number <br /> -11 <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name ` Property Location q <br /> Te r l" p,9 u/sp C 1/4 5 1/4,S T_FT-r ,N,Ir/YE(or <br /> Property Owner's Mailiq Address Lot Number Block Number <br /> `— <br /> City,State Zi ode Phone Number Subdivision Name or CSM Number <br /> r'+ J y r <br /> 6-y99'd c ) d3-.2y7 9 <br /> II.Type of Bui mg: (check one) ❑City / <br /> I or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> Public/Commercial(describe use):_ — 4own of <br /> / t� Z <br /> ❑ State-Owned 4) /�'�S 1oo <br /> Nearest Road <br /> tJ Parcel Tax umbers ' <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑ ddition to <br /> System System Tank Only Existing System <br /> B) 11Permit Number Date Issued <br /> A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> on-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 /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 30 6 y2 , 7 qG / fs-,11 <br /> VII.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 /> r Jill- ❑ ❑ ❑ ❑ <br /> S Ac Jj o 7Sa <br /> yI�7 <br /> SOd D �Z— ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature stamps): MP/MPRS No. Business Phone Number <br /> is lPa�lel,- i Z 76 q/ 7Y9 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> of Sir w 7-2 <br /> IX.County/Department Use Only <br /> ❑Disapproved I Sanitary Permit Fee(Includes Groundwater Date Issued suj it s <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination t 7 <br /> X.Conditions of Approval/Reasons for Disapproval: ` 3 2 <br /> 46 <br /> NETT COUNT, <br /> ZONING <br /> SBD-6398(R.07/00) <br />