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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 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 <br /> [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 I 1 inches in size. <br /> County State SanitarPermit Number ❑Check if revision to'pre ious application State Plan I.D.Number /i <br /> / <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location J� <br /> /I,�rl/1/4 14 S T ,N,RYE or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> z?s I <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> W1 S )2:66-67-No >l 17 1'• R7- <br /> 11.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 7 ❑Village <br /> ElPublic/Commercial(describe use): Town of 0 <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. j5Mew System 2. ❑Replacement 1 3. ❑Replacement of 4. ❑Addition to I Tax Nu er(s'I '/ <br /> System Tank OnlyExistingSystem —�/ <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> rl. <br /> Type of POWT System: (Check all that apply) <br /> on-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> Dispersal/Treatment Area Information: <br /> sign Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> (043 (4g .7 q$.4- <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> K I ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature( o s s): MP/MPRS No. Business Phone Number <br /> c►��►ap 22S$S� '76- &6- 415`7 <br /> umber's Address(Street,Ci ,State,Zip C e) <br /> 7--Mo 3� IA 65u <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Pe it (Includes Groundwater Date Issued Issuin ern o stamps) <br /> '1Approved ❑Owner Given Initial Adverse Surcharge F Od ©/ <br /> Determination ' <br /> IX.Conditions of Approval/Reasons for Disapproval: 7 <br /> SBD-6398 R07/00 <br />