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Safety&Buildings Division <br /> Sanitary Permit Application 201 W.Washington Ave. <br /> r In accord with Comm 83.21,Wis.Adm. Code PO Box 7302 <br /> See reverse side for instructions for completing this application Madison,WI 53707-7302 <br /> (Submit completed form to county if not <br /> Visconsin Personal information�ovacy Law Rsasecondary purposes 15.04(1)(m)] state owned.) <br /> Department of commerce <br /> Attach complete plans(to the county copy only) oCr the ifree ron to revious a li ation8 State Plan 1.D.Number <br /> County State Sani P MJ r 9�e <br /> Location: <br /> I.Application Information-Please Prin all Information Property Location U <br /> (o <br /> Property Owner NameIY <br /> /{I Cj 1/4 S Ct/1/4,s.2,:1-T.3 7,N, <br /> % <br /> p t- r z' O Lot Number Block Number <br /> Property Owner's Mailing Address /� ` AIA <br /> of S/ e- " ' a Phone Number Subdivision Name or CSM Number <br /> City,State }� Zip Code y -7 /M <br /> ✓6 <br /> .8(1 Yl � ❑City <br /> II.Type of Building: (check one) ❑village <br /> I or 2 Family Dwelling-No.of Bedrooms: Town of <br /> ❑Public/Commercial(describe use):_ 906 S ,/G <br /> ❑State-Owned Nearest Road'�?7 <br /> Uhe fte, <br /> Parcel TaXNuntber(s)Off- aa_ _Q <br /> III.Type of Per (Check only one box on line A. Check box on line B if applicable) 5 6. ❑Addition to <br /> A) 1. ❑New 2. Replacement 3. ❑Replacement of 4. Existing System <br /> System System Tank Only Date Issued <br /> 111111 Permit Number <br /> B) ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) ound ❑Sand Filter ❑Constructed Wetland <br /> ❑Non-pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> 13 Pressurized In-ground ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> ❑At-grade <br /> V.DispersaVTreatment Area Information: 4.Soil Application 5.Percolation Rate 6.System Elevation 7 Final <br /> Grade <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area Rate(Gals./day/sq.ft.) (Min./inch) ' <br /> Required Proposed / I D <br /> `! <br /> 5,L) II `/ Plastic <br /> sem ' � 1® D <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- <br /> VII. <br /> Gallons Gallons Tanks Con- Con- glass <br /> Information NExisting crete structed <br /> ew <br /> Tanks Tanks ❑ ❑ ❑ ❑ <br /> SL /t,oJ J voJ ❑ ❑ ❑ ❑ <br /> P 60J O 6 JJ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown PTP No. <br /> plans. Business Phone Number <br /> Plumbers Name(print) Plumber's Signature(nos Ps): RS x 333 <br /> �L Ty L�Lsr� <br /> Plumber's Address(Street,City,State,Zip d <br /> IX.County/Department Use Only <br /> ❑Disapproved Sani (Includes Groundwater Date Issued Issuing ent Signature(No stamps) <br /> tary Permit Fee <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee) <br /> a� <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: j III <br /> SEP 2 ? 2002 <br /> 3(J'RiVETi C( U <br /> SBD-6398(R.07/00) <br />