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Sanitary Permit Application Safety&Buildings Di'ssion <br /> •`'�► In accord with Comm 83.21.Wis.Adm. Code 201 W.Washington Ave. <br /> •, et�OnSin <br /> Sec reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may he used for secondary purposes Madison.WI 53707-7302 <br /> • Department or Commerce (Submit completed form to county if not <br /> I Privacy Law.s. 15.04(1)(m)) 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 /> County G f_ D � Stale Sanitary Number ❑Check if revision to previous application State Plan I D.Number <br /> Darle.I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> WA/ SW-Z. NW 1/4 KW 1/4,S.240 T ° ,N,RBE ow* _ <br /> Property Owner's Mailing Address Lot Number Block Number <br /> F50i$ c at,L pot. _ — <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Cross Pidttns, W i - ( ) Fpm • <br /> H Type of Building: (check one) ❑City <br /> I or 2 Family Dwelling-No.of Bedrooms: 4 ❑Village <br /> ❑ Public/Commercial(describe use): IS Town of <br /> ❑ State-owned DAN►e. <br /> Ill Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> (dxti-Spnr id Rd. <br /> A) I. ❑New System 2. 4 Replacement 3. ❑Replacer•ent of 4.Rl� dtliti r 70 Parcel"ax Number(s) <br /> I System I • Tank Only rl L•zistii'' y=r.ti ogP--oet08-+DA- �0-3 <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) I , <br /> • ❑Non-pressurized In-ground Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground I lolding Tank ❑Single pegs ❑L rip Line <br /> ❑At-grade ❑Aerobic Treatnent U W E COUNTIEitiifiaflaTtL ❑ether: <br /> DEPARTMENT - <br /> V Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.DispersalArea 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.S stem Elevation 7.Final Grade <br /> Required Proposed Rate(Gels./day/sq.ft.) (Min./inch) ` AT Elevati� <br /> (aL�(7 Ixz t` ii-V a- 41-.1' , 5 sae �srrE, <br /> VI Tank Capacity in Total fl of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> ScpCi� +XvtIC l'G0 — (SW i Meade. tg. ❑ ❑ ❑ ❑ <br /> pump 1-041k 9O O — g� i Meade. ❑ ❑ ❑ ❑ <br /> vv <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 /> tnilfe ■ Me1(k1/L IL AN A). lr\ruij x`05 eat-eiCe <br /> Plumber's Address(Street,City,State.Zip Code) <br /> (des!)-) at t. •`/ k Wau►^ove, Wk 5 i ) <br /> VIII County/Department Use Only • <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issui ent Signature(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> G "2 0 .4.2 6 � (�IC_J�� <br /> Determination Q+� 7---e. <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> ---- . .19t_70ef--e..: . /11-0, ‘-' -----■tc-±_i_ e'e-,- {1 <br /> .4(4,;,de 1 r . <br /> SBD-6398(R.07/00) , <br />