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Sanitary Permit Application Safety&Buildings Division <br /> ' 201 W.Washington Ave. <br /> In accord with Comm 83.21,Wis.Adm. Code 8t <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.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 syAtem,on paper not tess than 8-1/2 x 11 inches in size. <br /> County State Sanitary P N ❑Check)�sio to pieviWs ap ication State Plan I.D.Number <br /> I.Application Information-Please Print all Information (� Location: <br /> Property Owner Name' Property Location <br /> (41*46 ✓3 1/4 AW 1/4 S A ,N w <br /> Property er's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> � 4 � <br /> II.Type of ding: (check one) ❑City <br /> I or 2 Family Dwelling-No.of Bedrooms: EIV <br /> Iolivae <br /> e <br /> ❑ Public/Commercial(describe use): 32 <br /> ❑ State-Owned 1 5 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. ❑New System 2. J�' eplacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numbers) <br /> /System Tank Only Existing System 03Q- 30-0)- <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was viousl issued <br /> IV.Type of POWT System:(Check all that apply) <br /> on-pressurized In-ground 11Mound ❑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 /> L Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Requited Proposed Rate(GalsJday/sq.R) (MinJinch) Elevation <br /> Seo 6ED I 6la 1 . S qS.G q$-(o <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Can- Con- glass <br /> New Existing `� trete strutted <br /> Tanks Tanks ('� <br /> 1-1 11 13 <br /> oo''�c�r�t�` SCJ YV ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume ER!pqnsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no ): MP/MPRS No. ,B siness Phone Number <br /> ►t"ARD NS 7-25851 ll$' b- <br /> umbels Address(Street,City,State,Zip ode) <br /> --Z-176 <br /> 1n11. S4a93 <br /> VIII.County/Departme t Use Only <br /> ❑Disapproved Sanitary Permit F cludes Gro��r�dvater Date Issued Issuing t Si ) <br /> �51mroved ❑Owner Given Initial Adverse Surcharge Fce) �O &0 <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07M <br />