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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 /> `�seonsinSee reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide be used for seconds Madison,WI 53707-7302 <br /> Department of Commerce Y P may secondary purposes Submit completed form to <br /> [Privacy Law,s. 15.04(1)(m)] ( P county if not <br /> state owned. <br /> Attach complete plans to the county copy only)for the systernzan paper not leiW than 8-112 x l 1 inches in size. <br /> County State Sanitary Permit N k if ' 1 n to previous ap li ion State Plan I.D.Number <br /> I.App cation Information-Please Print all Infd'r—mdiioA f <br /> S Location: `OJ l <br /> ProOwner Name Property Location Jr ( <br /> WIM 1/4 1/4 S N E 00 <br /> Owners Mailin Address Lot Number <br /> Ci tate �• <br /> city, Zip Code Phone Number Subdivision Name or CSM Number <br /> II.Type of Building: (check one) ❑city <br /> ❑ 1 or 2 Family Dwelling-No,of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): Town of <br /> ❑ State-Owned j <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Roa OLID <br /> A) 1. ❑New System 1 2."�'*eplaccment 3. ❑Replacement of 4. ❑Addition to Parcel T umb s <br /> System Tan k Onl Existin S stem p 2 533 D 200B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> V.Type of POWT System:(Check all that apply) <br /> JoWon-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 /> D Required Proposed Rate(Gals./day/sq.0.) (Min/inch) Elevation <br /> Zq 32 '1 r-` R3 -o q6 .0 <br /> VI.Tank Capacity in Total ! <br /> of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> ❑ ❑ ❑ ❑ <br /> C ✓� 2 yy� ❑ ❑ 13 ❑ <br /> VII.Responsibility Statement <br /> 1,the undersianed,assume res usibility,for installation of the POWTS shown on the attached plans. <br /> Plu bees Name(print) Plumber Signaturo o a ): MP/MPRS No. Business Phone Number <br /> P ?zSBSI 1S - 41S <br /> P bees Adddr-e'/ss(Street,City,State,Zip ) <br /> / (- <br /> VIII.County/Department Usi Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date I ued Issuing i s) <br /> ❑Owner Given Initial Adverse Surcharge ) <br /> Determinatic 44 <br /> 1 1 <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />