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Sanitary Permit Application Safety&Buildings Division <br /> 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 /> Visconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of 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 system,on paper not less than 8-1/2 x 11 inches in size. <br /> Cou P State Sanitary rmit Number ❑Ch k if revjsion to previous plication State Plan I.D.Number <br /> �a <br /> I.Application Information-Please Print All Information Location: <br /> Property Owner Name J� {/— Property Location 0c. c� <br /> F �G! �v �/✓ I I.JIl4A)1/4,S j;?,T/G,N,R`E or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subtdiviirietr Name or CSM Number <br /> C 'tm llat '-4 nJ 5 5�3/ ( ) V :ZsZ v <br /> II.Type of Building: (check one) ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> 13Public/Commercial(describe use):_ _--� �I'own of <br /> ❑ State-Owned TAI— k—-5(D P' J <br /> Nearest Road <br /> A-fo 7 <br /> Parcel Tax Numbers) ,-c <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> Won-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.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.R.) (Min./inch) Elevation <br /> ysG 6 S 3' e<ve , '7 9:3, 5 9z.p <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> `` Tanks I Tanks <br /> S� Tic ODd r— d S/1/a/ W ec c3 El ❑ ❑ <br /> /Od ❑ — <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> G-)44le- A0,C411 1 61J.,,11 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> oX 3'/4/ ff,;�' e.J S Yk7Z <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit F e(Includes Groundwater Date I ued Issuing Agent Signa s) <br /> .Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> i <br /> AUG 2 q 2002 <br /> 13URNPrz / <br /> ZONING <br /> SBD-6398(R.07/00) <br />