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toad. pct IS � /?too n <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> ViMadison,sconsin Personal information you provide may be used for secondary purposes WI 53707.7302 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the syste n paper not les than 8-1/2 x 11 inches in size. <br /> Couy¢y State Sanitary Permit Number �`❑�z k if re . n to vious applies'on State Plan I.D.Number <br /> C4/.^j � 9 25 ria 7 <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner NameProperty Location E r <br /> G-Arr e <br /> s ns el er 1/4 1/4,S�77T�7/N,R"C(or) <br /> Prrooperty Owner's Mailing Address Lot Number Block Number <br /> City, tate Zip Code Phone Number Subdivision Name or CSM Number <br /> G/'&j5bpr w 8Yo <br /> II.Type of B ding: (check one) 0 City <br /> ` r- 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ Town of <br /> ❑ State-Owned /- of/ P— <br /> Nearest Road <br /> G4iv�1G— "`, 1 S <br /> Parcel Tax Number <br /> i5.a7 C5 a 6 <br /> II1.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. I&Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground �#Iolding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade p Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment 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 /> 'i7o O <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete strutted <br /> // !s Tanks Tanks C <br /> (din• LE3❑ ❑ ❑ ❑ <br /> VIII.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 Signam (no stamps): MP/MPRS No. Business Phone Number <br /> c)�-de- � wu ?k)/,* Cv. .2Z7Z 771 7�k� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Iss ' g ent Signa (No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) 7m� 3 0 0 3 <br /> Vjj <br /> Determination ou <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />