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w ' <br /> Sanitary Permit Application Safety& Buildings Division <br /> In 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 /> dSCOfS//] <br /> Partment of Commerce Personal information you provide Wray be used for secondary purposes Madison,WI 53707-7302 . <br /> [Privacy Law,s. 15.04(1)(m)J (Submit completed form to county if no: <br /> state owned.; <br /> V Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. t <br /> Cau State Sanitary Permit Number 0 Check if revision to previous application State Plan I.D.Number <br /> 6 i - c'LN 3Wo3is'3 <br /> I. Application Information- Please Print all Information Location: 1 <br /> Property Owner Name Property Location <br /> P 14 T r o n 7-1., ...1 .47 D rut.1/4/401/4,S.74 T 8 .N.Rt.2E(or' '- <br /> . <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 57 Li P1 LA nJGt/2- R D . I _ <br /> City,State Zip Code Phone Number . Strbdtxirron-Name ori Number ' <br /> 11 5 1449 ►- 1411 -5'..3r i ( 4,o t ) ;4.r:. 51Y31 S',1 .t r <br /> II Type of Building: (check one) mss' ❑City <br /> I or 2 Family Dwelling—No.of Bedrooms: rsi ❑ Village <br /> 0 Public/Commercial(describe use): \ / I fjZTown of <br /> ❑ State-owned \ /U/ e I, ' /v A <br /> III Type of Permit: (Check only one box on line A. Checkbexo t' if applicable) Nearest Road <br /> LAi,1LEf"- <br /> A) I. 0 New System 2. 0 Replacement 3. Replacement of 4. ' on to Parcel Tax Number(s) <br /> System Tank Only /} xistin j em _ • 6 S 1 1. •;02. • 90 00-7 <br /> B) "—Permit-Mumbet-- (J Date Issued <br /> 621 A Sanitary Permit was previously issued ' J J ,r' L / ?8 . p # J iiw ..S— ,c5-- <br /> IV.Type of POWT System: (Check all that apply) <br /> jitNon-pressurizedIn-ground e-- jri A/C • 0 Mound 0 Sand Filter R rcted Wetland <br /> ❑Pressurized In-ground Holding Tank 0 Single Pass FD <br /> ❑At-grade 0 Aerobic Treatment Unit 0 ppRecirculatirQ } rOther: <br /> ,� ��77 t <br /> V Dispersal/Treatment Area Information: `� �1e �.o e. xz 7-.:4 &, <br /> I.Design Flow(gpd) 2.DispersalArea 3.Dispersal Area 4.Soil Application 5.Percolat Ra{'r11)r s m Elevation 7.Final Grade <br /> Required Proposed 1.ra O Rate(Gals/day/sq.ft.) (Min/inch) (nth 0. QOrfy,� t Elevation <br /> al <br /> VI Tank Capacity in Total #a of Manufacturer Prefab Sit Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing \ crete structed <br /> Tanks Tanks <br /> /ar <br /> =,.#rte �iMF � S>. t-? 7 p res G..,Qe • <br /> I y-,p 1t1F/ S E /e - <br /> g <br /> 0 <br /> ❑❑ 0 <br /> 0 <br /> 0 <br /> it aA�Adf <br /> VII Responsibility Statement • <br /> ' I,the undersigned,assume res onsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no stam 190P/MPRS No. Business Phone Number <br /> Pec-eco r J germs e/ 4, d 3 c f 7 408' - v ,rs=.3902- <br /> Plumber's Address(Street,City.State,Zip Code) <br /> a y, 13 .4-4- r rt n C t p--i rt2 s 1t .o 1.— Le—,1 „J' 3 5 9 <br /> VIII County/Department Use Only <br /> 0 Disapproved Sanitary Permit Fcc(Includes Groundwater Date Issued Issuing Agent Signa stamps) <br /> Approved 0 Owner Given Initial Adverse Surcharge Fee) �' <br /> Determination / (c ,,, 9—C-)/ ___,----4-"r - -- -, <br /> IX. <br /> - <br /> IX.Conditions of Approval/Reasons for Disapproval: --- / <br /> NT1NG THIS APPROVAL•D ITSELF <br /> IN Gam` OR SPECIFICA- <br /> ENVIRONNIN�ALDEFF HEALTH <br /> PLANS HOLD <br /> LIABLE FOR A MINATIOtJ OVER- <br /> . . •LAN ONAISS{ONS, DAMAGE T►�AT MAY <br /> SIGHT.CO - • <br /> � OR ADDITIONS <br /> RESULT IN OR A�ERp,R HANGEST , , <br /> THE RIGHT TO ORDF. . THIS <br /> SHOUt U COl4D�IT{0145 l�IitSf NtAKING <br /> NECESSARY. <br /> 111_AZos.(0 A-f inn. <br />