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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 /> Seer verse side for instructions for completing this application PO Box 7302 <br /> Visebmin Personal formation 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 (f <br /> state owned.) <br /> Attach complete plans(t the county copy only)for the system,on pap r not less than 8-1/2 x 11 inches in size. <br /> County i� State Sani r� ❑ eck if revision to previ s application State Plan I.D.Number krn�Tl !Information <br /> I.Application Information-Please Pri Location: <br /> Property Owner Name Property Locationj� <br /> r°V i`N Lft 14,1-& D SS U k-" 411/4&1j][14,S 2/T37,N,RIOE(o W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Grtukbvr wfr V0 1CLS- ) qb'8 ?990 am v q p <br /> II.Type of Build g: (check one) ❑City <br /> ,» 1 or 2 Family Dwelling-No.of Bedroo s:�_ ❑Village <br /> ❑Public/Commercial(describe use):_ !9 Town of /,, <br /> ❑State-Owned _ry4AP ""eQ <br /> Nearest Roady; "4:7_yr /' <br /> Parcel Tax Number(s)03q-�S—Z d <br /> 111.Type of Permit: (Check only one bo on line A. Check box on line B if applicable) <br /> A) 1. Ll New 2. 19 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 is ued <br /> IV.Type of POWT System: (Check all th it apply) <br /> ❑Non-pressurized In-ground IS 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 Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> v S 0 <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing �t // crete structed <br /> Tanks Tanks l.-(7t�p0 <br /> �rc Y- aDO S� ❑ ❑ ❑ ❑ <br /> X ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibili for installation of the POWTS shown on the attached plans. <br /> Plumber's Namerint) PI be's Signatu (nos ps): MP/MPRS No. Business Phone Number <br /> 17/7 <br /> Plumber's Address(Street,City,State,Zip Code) _ <br /> ((Re; 3 <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary I'Sprut Fee(Includes Groundwater Dates ed Issuing a Si tamps) <br /> 1 proved ❑Owner Given Initial Adverse Surcharge a 1 0 {� i <br /> Determination I <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R 07/00) <br />