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—Safety&Buildings Division <br /> Sanitary Permit Application 201 W. Washington Ave. <br /> In accord with Comm 83.21, Wis. Adm. Code PO Box 7302 <br /> Vhwonsin See reverse side for instructions for completing this application Madison,WI 53707-7302 t <br /> Personal information you provide may be used for secondary purposes (Submit completed form to county i` "" < <br /> Department of Commerce [Privacy Law,s. 15.04(I)(m)] <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x I I inches in size. <br /> County State Sanitary P rmit Numb Li Check if revision to previous a plication State Plan 1. . umber <br /> 1. Location: <br /> Application Information- Please Print all Information () t <br /> Property Owner Name PSope� Ocation W� Y� <br /> h- Zia,S d— -3f .N,RTE(o <br /> Q ` Lot Number Block Number �. <br /> Property Owner's Mailing Address /+'y'µ n / <br /> ,see S'9 I 1.-f pS-�` AY�/C4r <br /> Zi Code Phone Number Subdivision Name or CSM Number <br /> �.State P <br /> ❑City <br /> 11 fype of Building: (check one) ❑Village <br /> O 1 or 2 Family Dwelling-No.of Bedrooms:_ GZ Town <br /> ❑ Public/Commercial (describe use): <br /> ❑ State-owned <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest ad I <br /> NSS <br /> A) 1. ❑New System 2. Replacement 3. ❑ Replacement of 4. ❑ Addition to Parr cl.�a�� urgber(s) rO�� / <br /> S stem Tank Only ExistingSystem U of `f `i <br /> cz <br /> B) Permit Number Date Issued <br /> ❑ A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) ❑ Sand Filter ❑Constructed Wetland <br /> ❑Non-pressurized In-ground .Mound <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 /> I Design Flow(gpd) 2. Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Require—dye Proposed Rate(Gals/day/sq ft.) (Min./inch) Q/ Q Elevation <br /> y <br /> VI Tank Capacity in Total q of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> Z lU�rS ❑ ❑ ❑ ❑ <br /> �— ❑ ❑ ❑ ❑ ❑ <br /> VII Responsibility Statement <br /> I,the undersigned.assume responsibilit for installation of the POWTS sho n the attached lans. Business Phone Number <br /> PI bet's Name(print) PI e' Sig ur (n tamps): MP PRS No- <br /> G Q►+�1� �� /�3 4, <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 673` ,DCS l2 /3 /3/tS�Fd�ir / <br /> VIII County/Department Use Only <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued IssuinVAge t Signa re s s) <br /> Approved ❑Owner Given Initial Adverse Surcharge e <br /> Determination V11 <br /> Oak ft) 11_7_oz) <br /> IX. Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />