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Sanitary Permit Application Safety&Buildings Division <br /> SIn 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 /> /scons�. Madison,WI 53707-7302 <br /> Department or Commerce Personal information you provide may be used for secondary purposes <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned. <br /> Attpch cont Tete lana to the county copy only)for the stem on paper not less than 8-1/2 x 11 inches in size. �f <br /> Counn, State Sanitary Per ❑chm if revi�sig2n..to previous app' tion State Plan I.D.Number <br /> N� 'rt (, ; <br /> L Application Information-Please Print n o ation Location: �� <br /> Property Owner Name Property Location /`� <br /> S I/4 1/4,S T O,N A or <br /> Property Owners Mailing Address t Lot Number Block Number <br /> !'� ve S S <br /> City,State m Zip Code Phone Number Subdivision Name or CSM Number <br /> WA CA e- G- rove Sro �S ys y-7ssy 6 55 L lOrP-5 <br /> II.Type o Building: (check one) ❑City <br /> ji�— 1 or 2 Family Dwelling-No.of Bedrooms: .r02 ❑village <br /> ❑ Public/Commercial(describe use): 351'Town of t <br /> ❑ State-Owned 41/U i 0 p <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road /�A T S Lk R <br /> A) I. New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System <br /> Tank Only Existing S stem B 0 Cl t) <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> PkNon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Linc <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 Elevation7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.fl.) (Min./inch) Elevation <br /> © C) Ya 4'3 2 -� '?'7./o455 t9 <br /> VI.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 /> 07�� Ovd d r4'J est ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> 1,the undersigned,assume reM2nsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumbers Signature(naS ): MP/MPRS No. Business Phone Number <br /> k4ol-e-4 i ;fly 10/1" GJ 2�7-7G 9,11, <br /> Plumber's Address(Street,City,State,Zip,Code) <br /> AV <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fly(Includes Groundwater Date Issued Issuing Ag t <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee <br /> Determination `Y�p�CJCJ mot <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 807/00 <br />