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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 /> V'Ksco�vsfn personal information you provide may be used for secondary purposes Madison,WI 53707-7302 )t 1 <br /> Department of Commerce [Privacy Law,s. 15.04(l)(m)] (Submit completed form to county if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)for ystem,on pap= of less than 8-1/2 x 11 inches in size. <br /> CountState Sani P i r e if revision to p vio application State Plan I.D.Number <br /> Gt o� 7 <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> �Dav: ( V�„�t � Oki A3 twN Gl /4,S 1'7T ,N,1�7(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 /> `�� 5`E8?a- ( )3�Fg- 2��1 4S l6 fD 2.l <br /> II.Type of Build ng: (check one) ❑City <br /> Q4 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑Public/Commercial(describe use):_ $Town of <br /> ❑State-Owned kNIC�S <br /> Nearest Road <br /> o�LtPw <br /> Parcel Tax Number(s) Z _ 700 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. CS 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 0 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 /> 4So <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks I Tanks <br /> (� 1w n ZSOo <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibi'ty for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print)) PI mber's Signa (no tamps): MP/MPRS No. Business Phone Number <br /> e(S C� -•r �2 ZZ i ^ <br /> Plumber's Address(Street,City,State,Zip Co e <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin Agent Signature(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) �� �a 0-5�a c <br /> Determination <br /> X. onditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />