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1 -�• Sanitary Permit Application Safety& Buildings I)1%ision <br /> In accord kith Comm 83.21. 11'is. Adm. Code 201 W. Washington Ave <br /> isconsin Scc reverse side for instructions for completing this application PO Box 7302 <br /> Department of Commerce Personal information you provide may he used for secondary purposes Madison.WI 53707-7302 <br /> II'rivacy I.mv.s. 15.04(1)(m)l (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 I I inches in size. <br /> County State Sanitary Permit Number ❑Check if revision to previous application State Plan I.D.Number <br /> :t.ve.. GO–C 45 ?)X 0--7 I X1013 <br /> I.Application Information- Please Print all Information Location: <br /> Property Owner Name <br /> Property Location <br /> Scp+k"-TheiS NWI/4 NEI/4,S30T7 ,N,RdE <br /> Property Owner's Mailing Address <br /> Lot Number <br /> Block Number <br /> BSI IU t-era( P)tvtit PG(- I — <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Ueror c Vv t -,'3 3 ( ) CSM eiSeka <br /> II Type of Building: (check one) ❑City <br /> GY I or 2 Family Dwelling-No.of Bedrooms: 14 ❑Village <br /> ❑ Public/Commercial(describe use): . t9�own of <br /> ❑ State-owned NA i4((etzn <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest yRooa��d Q � <br /> rCJ4Y ��//Q • 4.. l <br /> A) I. la'New System 12. ❑Replacement 3. ❑ Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System I Tank Only I Existing System '1-f35CY7-5 <br /> B) Permit Number ate Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) • NOV 7 2000 <br /> O Non-pressurized In-ground B"Mound ❑Sand Filter O Constructed Wetland <br /> 0 Pressurized In-ground ❑Holding"tank • s �• r;O � ' <br /> O At-grade ❑Aerobic Treatment Unit �' i ■ j X� <br /> li <br /> ea • -pdrtment <br /> V Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.DispersalArea 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.R.) (Min finch) SET AT Elevation <br /> CoDU (2(x)41-Z L 5 SITE SE-t-AT <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 /> Er <br /> S&( is ialAt:. Ito. () — Ito I ❑ ❑ ❑ ❑ <br /> Niec+ct L <br /> pump -t-a►ntc. �o — _ o I Ictci c ❑ ❑ ❑ ❑ <br /> VII 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 /> • <br /> Mdvew Mei tntn 012. _ ,,,-1116C- Leo MrAz- 27 at i. <br /> l 8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> c>1 C-p. 1-w1/41. k Wai-ivv,Vcee, '\fl <br /> VIII County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Data Issued 1 i n nt Signat re 'o 'amps) <br /> pproved ❑Owner Given Initial Adverse Surcharge gc) I I <br /> X.,.ttt <br /> Determination �(p f� , C D /�h/ /// <br /> IX.Conditions of Approval/Reasons for Disapproval: Ar /- <br /> / <br /> o 7 o '0 /-6'?00 a <br /> SID-6398(R.07/00) <br />