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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1.Wis.Adm. Code 201 W.Washington Ave. <br /> x 7302 <br /> NVAseonsin See reverse side for instructions for completing this application PO Madison,WI 5537707-7302 <br /> Department of Commerce Personal information you provide may be used for secondary purposes <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned. f S1 <br /> Attach complete plans to the county copy only)for the system,on papern t less tffiam112 x l 1 inches in size. <br /> County C� N State Sanitary Permit N if revi 'o t previous plication State Plan I.D.Number/_ �� <br /> I.Application Information-Please Print a o ation Location: (Q <br /> Property Owner N e Property Locatiort� '7� C W 1/4.1/4 S .2 T30,N R�� or <br /> 14V <br /> Property Owners Mailing Address Lot N r Block Number <br /> City,Stafe Zip Code Phone Number Subdivision Name or CSM Number <br /> S e� t-j I r %X 72 <br /> il.Type of Building: (check one) ❑city <br /> ItI or 2 Family Dwelling-No.of Bedrooms:�— ❑Village <br /> Public/Commercial(describe use): -Town o �t�"� t <br /> ❑ State-Owned /rim <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Near t Roadk ! T <br /> nJr � / U 6i7�vfUi✓ <br /> A) 1. ❑New System 1 2. .Replacement 3. ❑Replacement of 4. ❑Addition to PaiFef t Number(s) <br /> System Tank Only Existing S tem O `C] Q (1 <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 X Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-made ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dis ersaUTreatmeat 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(GalsJday/sq.ft.) (Min./inch) Elevation <br /> YS-0 V yrU r Y4 3 /d <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> InformationGallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> S.e //c <br /> 000 /Oo0 ❑ ❑ ❑ CI/ <br /> Nm b e d ❑ ❑ ❑ ❑ <br /> I.Resp nsibility Statement <br /> I the undersigned,assume res 'ibility for installation of the POWTS shown on the attached plans. <br /> Plumbers Name(print) I Plumbers Si tum no stem s): MP/MPRS No. Business Phone Number <br /> Plumbers Address(Street,City,State,Zip Code) <br /> oX % e,-L) <br /> VM. <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee ludas Groun ter Date ssued [saui t <br /> / pgroved ❑Owner Given Initial Adverse Surcharge F 60- <br /> I <br /> yi <br /> Determination J'�` !/ <br /> IX.Conditions of Approval/Reasons for Disapproval: 77 <br /> SBD-6398 R07/00 <br />