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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 n <br /> 1 6consin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 X <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned.) ' r <br /> Attach complete plans(to the county copy only)forth stem,on paper of less than 8-1/2 x 11 inches in size. V <br /> County <br /> State S i e r ❑C c if rev ion to previous plication State Plan I.D.Number <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name �/ Property Location 1- <br /> kO �'/�' 1/4 1/4,S& T3! ,N,R/7(or <br /> Property er's Mailing Address Lot Number Block Number <br /> City,State Zip l5ode Phone Number ,Sebdirision-Nmrle or CSM Number <br /> s ;Clev `S// " � /pr <br /> Il.Type of Building: (check one) ❑City <br /> %- 1 or 2 Family Dwelling-No.of Bedrooms: a ❑rd Village <br /> ❑Public/Commercial(describe use):_ WTown of <br /> c <br /> ❑ State-Owned �A ,uI �/S <br /> Nearest Road /c/ <br /> Parcel Tax N s) L <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) 66 <br /> A) 1. ew 2. 11 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 Molding 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 T 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 Tanks <br /> o/ani^- 666 66L d`2 j�i�w ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <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 Signature(no stamps): MP/MPRS No. Business Phone Number <br /> / T <br /> Plumber's Address(Street,City,State,Zip Code) or <br /> Q°X -5—/!y S/r` Cf^-, G✓ Sc/87.,-7 <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Yye(Includes Groundwater Date Issued Issuing A Sign s) <br /> `Approved ❑Owner Given Initial Adverse Surcharge Fee <br /> Determination Q D <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R 07/00) <br />