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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 /> Vvi.Scon$ih <br /> ofi Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of C merce (Privacy Law,s. 15.04(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 n t less than 8-1/2 x I 1 inches in size. <br /> County�vR�JeTT State Sanitary Permit Nu be Che if revision to p evious pplication State Plan 1.D.Number <br /> �l co• o� <br /> I. Application Information- Please Print all Information Location: <br /> Property Owner Name Property Location P& <br /> ,/6ot/.Lor5 1Z 1 13 <br /> DAV 1 p Pe 1, ry <br /> R, 1/4 1/4,S. T 40,N or W U) <br /> Property Owner's Mailing Address Lot Number Okwk-Namber <br /> E 43 70 4'&2 rd a v. z <br /> City,State Zip Code Phone Number Stt &*6ien-Nameor CSM Number <br /> MENom 0�1 G (A/I s�-75 / ( 7/S ).132 9476 Vol S Pos�lF/.7/5 <br /> II Type of Building: (check one) ❑City <br /> V( 1 or 2 Family Dwelling.—No.of Bedrooms:_ ❑Village <br /> O Public/Commercial(describe use): <br /> RTown of 3-AG00A <br /> ❑ State-owned <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road RI«+18 <br /> A) 1. eNew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Only Existin S stem t7 -A O y00 <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> eNon-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 /> I.Design Flow(gpd) 2.DispersalArea 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 /> 450 .3f145- 353 1 /.2 ,r/ 96. 4 99. 7 <br /> VI Tank Capacity in Total 4 of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks I Tanks <br /> Iceo ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ o <br /> VII Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(pri ) Plumber's Signature(n tamps): MP PRS No. Business Phone Number <br /> Gr/ f S�� 9 Y JZ� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> .E�e )e- <br /> VIII <br /> lVIII County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee uncludes Groundwater Date Issued Issuing A nt�r stamps) <br /> ❑Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination (�{`�I/ 75_lyl /Q� � 00 <br /> IX. Conditions of Approval/Reasons for Disapproval: <br /> 4Rn 0'198 IR 07/001 <br />