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Sanitary Permit Application <br /> In accord with Comm 83.2 1.Wis, Adm. Code Safety&Buildings <br /> N iseonsin See reverse side for instructions for completing this application 201 W. Washi B ve. <br /> Department of Commerce Personal information you provide may be used for secondaryPO B <br /> [Privacy Law,s. 1 s,p4 1 m Purposes Madison,WI 53707 2 <br /> ( )( )) (Submit completed form to coun_ n t <br /> Attach coin lete laps to the coun co onI )for the s stem,on a er not less than 8-1/2 x 1 1 inches in size. state <br /> County State Sanit Pe <br /> rtnjjt tuber ❑C k if revision to revio application State Plan L D.Numbe <br /> I.A ication Information-Please Prin all I for a ion <br /> Property Owner Name Location' <br /> S Property Location <br /> Property Owner's Mailing Address I/4 Ii4.S /q T�N /A <br /> E <br /> a WSy 144+1-I}- <br /> /T J1Y- Lot:Number Block�•—�- <br /> City,State -�� .S <br /> /i� • Zip Code Phone Number • L J <br /> fir' MN �S/l.y Subdivision Name or CSM Number <br /> II.Type of Building: (check one) <br /> e• ( �` I��6'(cogg <br /> I or 2 Family Dwelling-No.of Bedrooms: 3 0 City <br /> Public/Commercial(describe use): ❑Village <br /> ❑ State-Owned ''Town of �5CO <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 12. "Replacement 3. ❑ Replacement of 4. ❑Addition to Parcel Tax Numbe�r(s) <br /> Svstem Tank Onl /w! <br /> B) Existing System <br /> 136Zg O� 00 <br /> A Sanita Perini[was 31 l Y issued Permit Number <br /> Date Issued <br /> IV,Type of PO WT System: (Check all that apply) <br /> ❑Non-pressurized In-ground �j <br /> ❑Pressurized In-ground .+y Mound ❑Sand Filter <br /> 11 ❑At- de ❑Holding Tank Single Pass ❑Constructed Wetland <br /> V.Dis ersal/Treatment Area Information: °Aerobic Treatment Unit <br /> O Recirculati ❑Drip Linen ❑Other: <br /> I.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area q <br /> Required Proposed Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> 4So Rate(Gals./day/sq.ft.) (Min./inch) <br /> •7 S0 /� Elevation <br /> VI.Tank 4sal I"� �� "17 5- qq-3 <br /> Capacity in Total #of Manufacturer <br /> Information Gallons Gallons Tanks I Prefab Site Steel I Fiber- Plastic <br /> New Existing Con- Con- glass <br /> Tanks Tanks crete structed <br /> 1000 1000 <br /> AV. Poop <br /> ElVII. Responsibility Statement <br /> ❑ ❑ ❑ <br /> I,the undersi ned,assume res onsibili for installation of the POWTS shown on the attached plans. <br /> Plumber's'Jame(print) Plumbei s Signature(no slam s <br /> L� P ) MP/MPRS No. <br /> U^/ Business Phone Number <br /> umbels Address(Street,City State,Zip Co e) <br /> 2.7760 'jS WE851EK W!- 54$93 ✓ <br /> VIII.county/Department Use Only <br /> ❑Disapproved Sanitary permit Fee(Includes Groundwa Date Irib ed <br /> proved ❑Owner Given Initial Adverse Surcharge Fee) Issuing A Si r <br /> PS) <br /> Determination I I '� Z�O Z <br /> IX. Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />