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Sanitary Permit Application safety at Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> `�seonslnSee reverse side for instructions for completing this application PO Box 7302 <br /> oepertmant or Commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> [Privacy Law,s.15.04(1)(m)] (Submit completed form to county if not (� <br /> Attach COMPrete lens to the county copy only)for the s temon r not less than 8-1/2 x 11 inches in size, state owned. }�J <br /> County <br /> State Sanitary P 't k" "sign to pe vi us a lication State Plan I.D.Number <br /> I.A cation Information-Please Print all Informfiticlu I La JOC Location: 00Property Owner Name <br /> Dog I L Property Location K\ <br /> Property Owners Mailing Address 1/4 01/4 S24A N E U <br /> It Number Block Number <br /> 4SvS AV.City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> S -77_9 IS OM- 634- Gpiff ASS <br /> VII ype of Building: (check one) p airy <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 2 ❑Village <br /> ❑ Public/Commercial(describe use): (Town of ^_0lss <br /> ❑ State-Owned —5 <br /> M.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. Iew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Pnicel Tax Num s <br /> S stem Tank Only ExistingSystem p <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System:(Check all that apply) <br /> on-pressurized In-ground ❑Mound ❑Sand Filter 13 Constructed Welland <br /> Pressurized In-ground ❑Holding Tank Cl Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other. <br /> V.Dis ersaill'reatment 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 /> Req re 1 Proposed Rate(GalsJday/sq.R) (Min./inch) ^�. Elevation <br /> 3_0 -2 Z -7 IIS IF 4 <br /> VI.Tank Capacity in Total 0 of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> Oro 1000 1 <br /> ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigmd.assume res nsibili for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumbers Signature( s s): ­MP/ <br /> MPRS No. Business Phone Number <br /> P bees AddressS S <br /> ( beet,City,,State,Zip ) <br /> ;Q two AACI -35 <br /> VIII.County/Department Ude Only <br /> ❑Disapproved Sanitary Permit FEft(Includes Groundwater Date Is Issuing Si s <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee <br /> Determination I <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />