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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> V iseonsinSee reverse side for instructions for completing this application PO Box 7302 <br /> Department of commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> Attach complete nlanq tto the coon co onl fo e system,on paper not less than 8-1/2 x 11 inches in size. state owned. <br /> CountState SanitaryPennit Num Ir ❑ k if r ision to previo application State Plan I.D.Number <br /> Al6Y/1 e ;Ira57a <br /> I.Application Information-Please Print a I formation <br /> Property Owner Name Location: <br /> 5�(('' // Property Location <br /> 0/A <br /> Property Owner's Mailing Address 1/4 1 <br /> /4 S T <br /> 3 0 9 p Lot Number Hlock umbe <br /> City,State Zi ode Phone Number Sub ision Name or CSM Numbe <br /> ��h .bur,.. W'J. .5�� <br /> II.Type of uI ing: (check one) ❑City <br /> Er 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): 0-Town of <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nast Road <br /> OX`Q R� <br /> A) 1. New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numb <br /> diM <br /> System TankOnl Existin S stem (93 _R16 UY 3oa <br /> B) Permit Number Date Issued <br /> 11A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> O Non-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 7T.-Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Ce// 26 ' Elevation <br /> 3 7S--1)"Z3 . 7 17 eii'eZ 90,ao 9� 869Y.8e , <br /> VI.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 Tanks <br /> ' ' Ll —0 —0 -0 <br /> A0 /out, � yV/rIe/J � /CfY <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersi ed,assume res onsibili for in <br /> of the POWTS shown on the attached plans. <br /> Plumbers Name(print) Plumbers Signature(no stamps): MP/MPRS No. Business Phone Number <br /> /i2 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> syr P;�� /1 °k /��! l✓��ff�� l✓;�. S5'�� <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Age Si re ps) <br /> ;roved ❑Owner Given Initial Adverse Surcharge Fe/� 0� 1b O <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />