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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 73 2 <br /> ��SConSin Personal information you provide may be used for secondary purposes Madison,WI 53707-7 <br /> Department of Commerce <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county it <br /> state own <br /> Attach com let e lans to the county copy only)for the s stem,on paperzQot less than 8-1/2 x I 1 inches in size. <br /> County State Sani Permit N e Che 'f revision to previous plication State Plan I.D.Number <br /> # as <br /> I.Apoication Information-Please Print alln r ation Location: <br /> Property Owner Name Property Location <br /> 1/4 1/4 S 'ZT N,R!; or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 51-14. 61 <br /> City,Sta a Zip Code Phone Number Subdivision Name or CSM Number <br /> �6nz,W W! 6401�O IS .IS $ k_� E O <br /> I):.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 2 ❑Village <br /> ❑ Public/Commercial(describe use): Town of G���,� <br /> ❑ State-Owned ,I7� 3oij <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road 6 ` <br /> A) 1. �ZDNcw System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel T Numbe s) <br /> System I Tank Only Existing System s O <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> .Type of POWT System: (Check all that apply) <br /> ❑ <br /> Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At- ade ❑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 Rete(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 300 4174+ 43 2- '� ,----� �7 �7 n <br /> VI.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 I Tanks <br /> PDO <br /> _ ❑ ❑ ❑ ❑ ❑ <br /> VII.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 /> AMA-W . Ada <br /> umbers Address(Street,City State,Zip Co e) <br /> 2.7760 35' W150M Wi. 554893 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit F e(Includes Groundwater Date Issue Issuing t Si re <br /> &P-proved ❑Owner Given Initial Adverse Surcharge Fee) X651- o <br /> Determination V <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />