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J, <br /> - .. Sanitary Permit Application Safety&Buildings Division <br /> WirIn accord with Comm 83.21.Wis.Adm. Code 201 W Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> se�nsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce p p (Submit completed form to county if not <br /> [Privacy Law,s. 15.04(1)(m)] <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system.on paper not less than 8-1i2 x I I inches in size. <br /> County I State Sanitary Permit Number ❑Check if revision to previous application I State Plan I.D.Number <br /> Vie. 0(°D5(5 I ((0O 13S <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> �-Q.. 'CNC\C Y ±•\ Y1-2.‘\\_ t4W1/4(NI 1_1/4.S 1ST—1 .N.RtIEIor)-W- <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> C i ce Q cN&- ._ \\ SAS a-1 (\per)P)32t-S3 e), '- <br /> II Type of Bundling: (check one) ❑City <br /> lid 1 or 2 Family Dwelling—No.of Bedrooms: '.3-.. ❑Village „ <br /> 3 Public/Commercial(describe use): own of <br /> 0 State-owned C..,Cec eoe-COY O N1-e._ <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road J <br /> a, -\_ ._.,..._., ._ . —�_� <br /> A) 1. New System J 2. ❑Replacement 3. ❑ Replacement of 4. ❑Additionto ., a <br /> System Tank Only Existine • ejn- -ti � `� <br /> B) IPermit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> t(Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank - • ❑Single Pass ❑Drip Linc <br /> ❑At grade ❑Aerobic Treatment Unit . .❑ Recirculating ❑Other: <br /> V Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.DispersalArea 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.Sys Elevation 7 Final Grade <br /> Required Proposed Rate(Gals./day/sq.R) (Min/inch) "75(�' Elevation <br /> �,,OC) 42q i-132 : o.7 Nil • . 98.S" <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 /> '�SeP�(c loco - tpoo I bC11 mac '� ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ 1 ❑ <br /> `II Responsibility Statement . <br /> I.the undersiened.assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plum is Signature(no stamps): MtaTri). Business Phone Number <br /> Steven J Tesmer • uc _A—.) 227116 920-478-2379 <br /> Plumber's Address(Street,City,State,Zip C e <br /> N8458 CTH 0 Waterloo, Wi 53594 . <br /> VIII County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued lssuin Agent Si. : re ' s) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) U�_ �*-.rviallir Determination �� �°b �' <br /> — :.ArAll■, <br /> IX.Conditions of Approval/Reasons for Disapproval: - • 1 - Il/ <br /> RECEIVED <br /> --•, 1 0 <br /> DANt CUUNIY tNVIiUN'•'L',IAC <br /> • <br /> DANE COUNTY ENVIR0NMENTAE HEALTH DEPARTMENT <br /> HEALTH DEPARTMENT <br />