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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> Visconsin <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> 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 /> Count� State Sanitary Permit Number 11C eck if tsion to previo application State Plan 1.D.Number <br /> p 4rAv � 4-34- L? fI �5�3 <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name_/ ,t Property Location <br /> �, r,+I; Q .� 01/4.-56-1/4,S.' TTY?,N,R!E(or) <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 33 7,;2 iso ` L,v. <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> /cJe�� c wT s`/83 7 ( )327-8576 <br /> II.Type of Building: (check one) ❑City <br /> 9�--1 or 2 Family Dwelling-No.of Bedrooms. 3 ❑Village <br /> ❑Public/Commercial(describe use):_ 1-- ;11-Town of <br /> ❑State-Owned G ✓ O <br /> Nearest R ad <br /> e '1G-/'Sa nJ <br /> Parcel Tax Number(s)Q <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. w 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> $) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> on-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.DispersaV]Preatment 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(GalsJday/sq.ft.) (Min./inch) Elevation <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 /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print Plumber's SignaturMP/MPRS No. Business Phone Number <br /> e no stamps): <br /> Lvi4�/�e �y��pi� GtJJ� 7-2�'� <br /> Plum�bbeees Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issin Signa stamps) <br /> Approved 1 ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination ` v'� 03 <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> So a-s Vevt(ri eo( ,-f,444 Y '03 <br /> MAY 3 o W3 <br /> SURNET`T COUNTY <br /> SBD-6398(R.07/00) <br />