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su <br /> Sanitary Permit Application Safety&Buildingson <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washing e. <br /> `viseonsin See reverse side for instructions for completing this application PO B 2 <br /> Department or commerce Personal information you provide may be used for seconds 2 <br /> secondary purposes Madison,WI 537 <br /> [Privacy Law,s. 15.04(I)(m)] (Submit completed form to county' of <br /> County ps <br /> Attach com le'te lato the county copy only)for the s Ste on a er not less than 8-1/2 x I l inches in size. stat <br /> State Sanitary Permit Numb r <br /> e ev's �t_preous ap lic ion State Plan[.D.Number <br /> I.A ication Information- Please Print all Information �Of <br /> Property Owner Name Location: <br /> VIN^E Property Location <br /> Property Owners Mailing Address '56 1/45W1/4,S T ,N,R'J 'or <br /> 3D�}K Sfi R l Lot Number Block Number <br /> City,State Zip Code <br /> / Phone Number Subdivision Name or CS\I Number <br /> = , <br /> II.Type of Building: (check one) 6a ) <br /> C3I or 2 Family Dwelling-No.of Bedrooms: — ❑City <br /> ❑ i <br /> C3Public/Commercial(describe use): <br /> ❑ State-Owned Towwnn <br /> of <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road /!/I <br /> A) 1. XNew System 2. ❑Replacement 3. ICReplacement of 4. ❑ Addition to Parcel raxNulmf aSvstem Onl Existin S stemL� Qj`B) ermit Number <br /> ❑A SanitaryPermit was reviousl issued Date Issued <br /> IV Type of POWT System: (Check all that apply) <br /> Non-pressurized In-ground ❑ Mound ❑Sand Filter <br /> ❑Pressurized In-ground ❑Holding Tank 13 Constructed Reiland <br /> ❑At-grade g ❑Single Pass ❑Drip Line <br /> E3 Aerobic Treatment Unit El Recirculating CD Other: <br /> V.Dis ersaU'Creatment Area Information: <br /> I.Design Flow(L) LDispersal Area 3Dispersal Area 4.Soil A lication uircd Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> 9 � / Proposed Rate(Galslday/sq.ft.) (Min./inch) <br /> 3Q0 Z1J� 7 �� 9`_ O Elevation <br /> VI.Tank Capacity m J 7 i ?g' 0 <br /> P ty Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks <br /> New Existing Con- Con- glass <br /> /Tanks Tanks / Crete sttucted <br /> VII.Responsibility Statement <br /> I,the undersi ned,assume responsibility for installation of the POWTS shown on the attached lans. <br /> Plumber's'Jame(print) Plumber's Signature(no stamps): MP/MPRS No. <br /> Business Phone Number <br /> U't� ?2S1S /S7 <br /> umber's Address(Street,City State,Zip Co e) <br /> Z77k 3S WEssr�x W1• S48G3 <br /> VIII.County/Department Use Only <br /> ,Q ❑Disapproved SanitaryPermit Fee(Includes Groundwater <br /> �t7 Approved ❑Owner Given Initial Adverse Surcharge Fee) M Date I ued Issuing g t Si , ps) <br /> N Determination <br /> IX. Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07;00 <br />