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eY <br /> Sanitary Permit Application Safety&Buildings Division <br /> J 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 /> 11 <br /> Wisconsin personal information you provide may be used for secoridary purposes Madison. WI 53707-7302 <br /> Department of Commerce [Privacy Law. s. 15.04(I)(m)] (Submit completed form to county if not <br /> state owned.) <br /> Attach comptete ptans(to the county cop),only) for the system.on a er of less than 8-1/2 x I I inches in size. <br /> County State Sanitaryrtni ❑Che jf revisjonntto previous plication State Plan I. D.Number <br /> 1. ApplicailAn Information - Please Print all Information Location: <br /> Property Owner Name Qn Property Location <br /> e W6S c3- Q. 1^ 5'e, A/ I/4 1/4.JT. (,y <br /> N.R/E� W <br /> Property Owner's Mailing Address Co_01 X ,p % Lot NN ber Block Number ` <br /> Cu N /1 CI t'JD V 1L to <br /> Ci State Zip Code Phone Number Subdivision Name or CSM Number <br /> II Type of Building: heck one) ❑City <br /> m I or 2 Family Dwelling—No.of Bedrooms: 3 ❑village <br /> O Public/Commercial(describe use): 0 Town of <br /> ❑ State-owned <br /> 111 Type of Permit: (Check only one box on tine A. Check box on line B if applicable) Nearest Road <br /> C- 7L,/-/ <br /> A) 1. ❑New System 2. I9 Replacement 3. ❑ Replacement of 4. ❑ Addition to Parcel Tax Number(s) <br /> System Tank Onlv Existing System 0� —� r�< — �>( <br /> B) Permit Number Date Issu� n <br /> A SanitaryPermit was previous]),issued D <br /> IV.T pe of POWT System: (Check all that apply) <br /> 21 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 ersalff'reatment Area Information: 7v C pnj er,I X /7, 7 <br /> 1.Design Flow(gpd) 2.DispersalArca 3.Dispersal Area 4.Soil Ap lication 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min.linch) (?o/� Elevation <br /> 37f 13 1. 2— 76"So-76, <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 /> [� ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII Responsibility Statement <br /> I the undersigned,assume responsibility for installation ofthe POWTS shown on the attached plans. <br /> Plumber's Name(print) Pum er's S' na a(n�sLamp : 14P/MPRS No. Business Phone Number <br /> 7� we l Y/I,c 23267 G 12/f Yra <br /> Plumbee Address(Stmt,City,State,Zip Code) / (y <br /> 401 60 l' )l u C �. �< 7 k13:— <br /> VIII County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing A Si n re ps) <br /> Approved ❑Owner Given initial Adverse Surchargetee) `; <br /> I�T <br /> Determination l <br /> IX.Conditions of Approval/Reasons for <br /> Disapproval: r ue`4- // <br /> �i Edi�7a �✓eVi'?j ed// Rvl� cJC�ler/� n'� _ �) / / <br /> .la Ye c� ! uJ ST�i-rl 4 rL�6Z l.J I(1 V2 1'•e i�L{ �V <br /> ?If s 'ped Z <br /> ��eU�77 l�U/ � /1 e sy.���-1 <br /> SBD-6398(R.07/00) <br />