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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington PO Box Ave. <br /> 7302 <br /> `�sconsin See reverse side for instructions for completing this application Madison,WI 53707-7302 <br /> Personal information you provide may be used for secondary purposes <br /> Department of Commerce (Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not (� <br /> state owned.) J <br /> Attach complete plans(to the county copy only)for the system,on paper niq less than 8-1/2 x 11 inches in size. <br /> County State$n ta� � Number ❑ ck if ision to previous a lication State Plan I.D.Number <br /> v <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> A/AA/4,f /4,S T3 ,N,R/t(or) <br /> Property Owner's Wailing Adcbresf Lot Number Block Number <br /> 2S ``l` ), /f"ol A <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> A-e_l 44(,t s Y L 7 1 ( ) 44A <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms:�_ ❑Village <br /> j$Town of <br /> Public/Commercial(describe use):_ <br /> ❑State-Owned {.t✓ c <br /> Nearest Road <br /> Parcel Tax Number(s) <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. New 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 ,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) leElevation <br /> L� ^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 /> ❑ ❑ ❑ ❑ <br /> Jd � b / 000 <br /> r✓t <br /> VIII.Res risibility 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(nostain s): MP/MPRS No. 7-1 <br /> usiness Phone Number <br /> � / _ � z 3 3 / s —`r�� �� 603 <br /> Plumber's Addr s(Street City,State,Zip"C e) <br /> l,✓ 9,4�/, / ✓t ✓ S `l 3 <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fe Includes Groundwater Date Issued Issui Agent Signature(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) '1 <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />