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Safety&Buildings Division <br /> Sanitary Permit Application 201 W.Washington Ave. <br /> Vsconsfn in accord with Coarct 83.21,Wis.Adm. Code PO Box 7302 <br /> 0aoartment of commerce Personal infomsatioa you Madison,W153707-7302 <br /> Y provide may used for secondary Proposes (Submit completed form to rfnot <br /> [Privary Law,s.15.04(I)(m)] state owned. <br /> ,y Attach complete plans to the countv copy only)for the system,on paper not errs than 8-1/2 x I 1 inches in size. <br /> CyJ G/p NLF TT <br /> State Saoitay P N m ispa to ious State Plan L D.Number <br /> L Appikation Information-Please Print ad Information Location: <br /> Property Owner Name qty,Location <br /> YA/z o ti 7) <br /> Property Ownces Mailing Address m I/4,S o2�T ,N.ck E( W <br /> Number Block Number <br /> Bc a i 3 /3 <br /> City,StateZip Code Phone Number Subdivision Name or CSM Number. <br /> SY 8 � © ( �r� ) �(v6� `�8`f� �k t Fes- �C�21=5 <br /> II Type of Building: (check one) . ❑city <br /> * l or 2 Family Dwelling—No.of Bedrooms:_ ❑Village <br /> O PubildCommercial(describe use): 03own of <br /> O State-owned <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) L New System 1 2. ❑Replacement 3. ❑ <br /> Rep Replacement of 4. ❑Addition to PacelTaxNumba(s► <br /> Svstcm Tank Only Existinx System O S —D a — 3p o <br /> B) IPermit Number DarelssmrW <br /> C3 Sari Permit was previously issued <br /> IV.Type of POWT System:(Cheek all that apply) <br /> %Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland . <br /> ❑Pressurized In-groand ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V Dia nal/Preatment Area Information: <br /> 1.Design Flow(gpd) 2.Diaper— 3.Disposal Area 4.Soil App motion 5.Percolation Rate 6.System Elevation 7.Final Cade <br /> Required Proposed Rate(OaWday/sq.R) (Mialinch) Devadm <br /> gym© 3b 7 17m o C) l0'' <br /> VI Tank Capacity in Total #of Manufacturer Prefab Site Steer! Fiber- Plastic <br /> Information Gallons Gallons Tanks coa- Con- glass <br /> New Existing <br /> FC$CaLZ erecter sttttcted <br /> Tanks Tanks <br /> Se fl�G -7S© 750 / P�vavLTS. ❑ ❑ ❑ ❑ <br /> VII Responsibility Statement <br /> 1,the undersi ed,assume nsibilifor installation of the POWTS shown on the attached plans. <br /> Phmbee&Nam(peen► Pl l ): MP/MPRS No. Business Phone Number <br /> � <br /> -Naobet's Address(Shea,City.State,zip Code) <br /> Ila-2 l 3 S, 574 7-,E /2/) 3 t Dig/--�u ' t Aj i SCJ e 3 c� <br /> VIII County/Department Use Only <br /> TO.,=roved Sanitary Permit (Includes Groundwater Date Is Issuing SiApproval Given initial Adverse Surchage F )7_ >�mination �lJ r/1� <br /> VL Conditions of Approval/Reasons for Disapproval: <br /> RECEIVED <br /> OCT t <br /> BORNET7-COQ <br /> ZONING NTy. <br />