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Cge4c* 37 / /.7— <br /> Sanitary Permit Application Safety&Buildings D' <br /> Wi' In accord with Comm 83.2 1,Wis.Adm. Code 201 W. Washingto <br /> sconsinSee reverse side for instructions for completing this application PO Bo. <br /> Department or commerce Personal information you provide may be used for secondary purposes Madison,WI 53707.73 <br /> (Privacy Law,s. 15.04(1)(m)) (Submit completed form to coup <br /> state o <br /> AttgLch complete plans to the countv copy only)for the system,on papcK not less than 8-1/2 x l I inches in size. <br /> CountyutoState Sanit eckli li ion t� v • um <br /> application State Plan 1.D.Number Q P hjyt»�r� ^ �./l <br /> I.Application Information-Please Print all Information Location: /v��f JL <br /> Property Owner Name / Property Location /► <br /> /, /so •� 1/4 I/4,S 4 T 38,N,R/� 'o W <br /> Property Owner's Mailing Address Lot Number onloek,44w ber <br /> Zq01 Allvckz A, a 9. L S <br /> City,State Zip Code Phone Number Subdivision Naine or CSM Number <br /> o/ 12rk IgAJ, I AtrZ ) 436- 9zo15 . ; A4V9.S <br /> II.Type of Building: (check one) ❑City <br /> ;Z] I or 2 Family Dwelling-No.of Bedrooms :- -3 ❑Village <br /> ❑ Public/Commercial(describe use): le Town of <br /> ❑ State-Owned 4 F <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Neare oa <br /> A) L ❑New System 2. CFReplacement 3. ❑ Replacement of 4. ❑Addition to Parcelmber(s) <br /> S stem Tank Onl Existin S stem _2201 H ()J <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System: (Check all that apply) <br /> ®'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 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (MinJinch) r*P 9#,7 Elevation <br /> / 6 U 61C< 4 • 7 E3od�tM?Z.6 V 7 <br /> VI.Tank Capacity in Total of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing I crete structed <br /> Tanks Tanks <br /> w <br /> Li ❑ 13 ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assumeres onsibiI for <br /> beinstallation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumr's Signature(nos mps): YIP/MPRS No. Business Phone Number <br /> 0lgans 22,SSS� <br /> P umber's Address(Sire t,City,State,Zip Code) <br /> VIII.County/Departme t Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date[ss'upd (ssu Agent Signature(No stampsi <br /> XApproved ❑Owner Given Initial Adverse Surcharge Feel, �}• '� �(,./�'./�^) <br /> Determination —� �� 1 u, <br /> IX Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07100 <br />