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C�7�;�9-maw <br /> Sanitary Permit Application Safety&Building,61PNAion <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washirve. <br /> PO <br /> 02 I <br /> See reverse side for instructions for completing this application Madison,WI 53 02 <br /> `�SCOIISi1iT11 <br /> Per information you provide may be used for secondary purposes (Submit completed form to co not <br /> Department of Commerce LPrivacy Law,s. 15.04(1)(m)] <br /> state owned. <br /> Attach com Tete lans to the countyco only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Permit Number L3Check if revision,to previous application State Plan 1.D.Nu Q <br /> 1.Aplificition Information-Please Print all Infordatlisn Location: <br /> Property Owner Name Property Location <br /> Y_ 1/4 1/4, ,N, or <br /> Propert7ONW,neejMailing Address Lot Number Block Numbe <br /> Vixr 04v y <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> (�08 5Z6- S IV !3 I28 <br /> I.Type of Building: (check one) ❑City <br /> ❑Village <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: Town of S <br /> ❑ Public/Commercial(describe usef <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road fir /I <br /> A) 1. ❑New System 2. Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number s) t <br /> System Tank Onl Existing System <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground ��`Ri'Iound ❑ Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑ Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 100. <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(Gals./day/sq.ft.) (Min./inch) Elevation <br /> VI.Tank Capacity in To"ofManufacturerr Prefab Site Steel Fiber- Plastic <br /> Information GallonsGalCon- Con- glass <br /> New Existingcrete structed <br /> Tanks Tanks ❑ ❑ ❑ <br /> VV <br /> t- <br /> VII.Responsibility Statement <br /> I,the undersigned,assume res onsibili 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 /> �k ?ZSSS/ 5- - /S7 <br /> umber's Address(Street,City State,Zip Co e) <br /> 27160 3S' In1£8M t^Jl- S4$93 <br /> VIII.County/Department Use Only <br /> ❑Disappr771ru:tl <br /> Sanitary Permit (Includes Gro water Date Issued Issuing A e Sign re ps) <br /> J proved ❑Owner Adverse Surcharge ee)Determina <br /> IX.Conditions of Approval/Reasons for Disapproval: 1 7 <br /> SBD-6398 R07/00 <br /> ZQIVI�6 T TY <br />