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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 /> Visconsin Personal information you provide may be used for secondary purposes Madison,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 system,on paper not less than 8-1/2 x 11 inches in size. <br /> Co fie <br /> u State Sanitary P it tube ❑C if revjsion to previous plication State Plan I.D.Number �Q <br /> /� e (J ° <br /> I.Application Information-Please Print all nformation Location: <br /> Pro a OwnerN a Property Location ' <br /> r\ <br /> oil- , Te <br /> 6,t rTe 7-aid 1/4 1/4,S o2 T3S,N,RI`E�,/(or <br /> Property Owner's Mailing Address / , Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or-e3l9r umber <br /> Cro/ �� 5-9'0;2 ( ��s > Y83- 99s3 S �.� hise Se4c-L <br /> II.Type of Building: (check one) ❑city <br /> ,ELI or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ 'Town of <br /> ❑State-Owned e 4j <br /> Nearest Road r <br /> Goa �/ ec <br /> Parcel T Number(s) <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ew 2. ❑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 01�Aound ❑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 Application 5.Percolation Rate 6.System Elevation 7,Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 3 ©d -700 301 /oo, 7 <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 structed <br /> / Tanks Tanks <br /> _- -520 d �-- ❑ ❑ ❑ <br /> pD ❑ <br /> Y� <br /> VII.Res onsibility 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 /> Plumber's Address(Street,City,State,Zip ode) <br /> ,do ?< S/ 5-//" e W I- -S- 8'72 <br /> IX.County/Department Use Only <br /> ❑DisapprovedSanitary Permit Fqq(Includes Groundwater Date Issued Issur Agent Signature(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) [ a� <br /> Determination ~v <br /> X. onditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />