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Sanitary Permit Application Safety.&Buildings Di <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washingto0� <br /> See reverse side for instructions for completing this application PO Bo N/!qi <br /> iseonsin personal information you provide may be used for secondary purposes Madison,WI 5370 <br /> Department of Commerce Submit completed form to coun t <br /> [Privacy Law,s. 15.04(1)(m)] ( p ty <br /> state o e <br /> Attach com tete plans to the county copy only)for the system.on paper not less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Permit Number heck, revision to prcous application State Plan 1.D.Number <br /> I.AppTication Information-Please Print valf In ormatio �( Location: et/ <br /> Property Owner Name Property Location <br /> 1/4 1/4,S N,R or W <br /> Property Owner's Mailing Address Lot Number Block Numbe <br /> 541 5 W,4 14-t c,1_ go— 7-4 <br /> City,State I Zip Code Phone Number Subdivision Name or CSM Number <br /> f✓ SS 7 47-5- 5567== ✓.V <br /> 11.Type of Building: ( heck one) Es city <br /> -0 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑ Public/Commercial(describe use): Jerown of ' <br /> ❑ State-Owned 5 4�s Al <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road 5+ � �!_ N nyi <br /> A) I. New System 2. ❑ Replacement 3. ❑ Replacement of 4. ❑Addition to Parcel Tax NuJ er(s) �"F��n/ Q�/Pe <br /> System I Tank Only Existing System 2- <br /> B) <br /> 11Permit 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 ❑ Holding Tank ❑ Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑ Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: ' <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application5.Percolation Rate 6.System Elevation Z Final Grade <br /> Re utred Proposed Rate(Gals./day/sq.ft.) (Min./inch) � n ��` Elevation <br /> DSD .S �� gs7_ g6.9 <br /> VI.Tank Capacity in Total ii of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> Im two l0911 ❑ ❑ ❑ ❑ <br /> L /�.,., 600 ❑ ❑ Cl ❑ <br /> VI .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 /> umber's Address(Street,Ci ry State,Zip Code) <br /> 2L-717/1K 35- WfaM WI. 54893 <br /> VIII. County/Department Use Only <br /> ❑Disapproved Sanitary P t Fee(IncludeWroundwater Date Issued - Iss Age n s mps) <br /> roved ❑Owner Given Initial Adverse Surcharge � j/}��VAwI <br /> Determination !J'�` <br /> LO <br /> Q� <br /> IX. Conditions of Approval/Reasons for Disapproval: <br /> SBD-6399 R07/00 <br />