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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 /> Viaeqnsin <br /> 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 [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not 7 <br /> state owned.) <br /> Attach complete plans(to the county copy only)for th system,on paper not less than 8-I/2 x 11 inches in size. <br /> County ')b Y f % r <br /> State <br /> t StaSanitait Number ❑Ch to previous State Plan I.D.Number45 <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location '/ <br /> (i It w N ct („C' ] I r t e 4 / r1/4,314/4,SZ y T&(,N,R��f(or)W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> /G qqqS -4w RA <br /> City,State Zip Code Phone Number// Subdivision Name or CSM Number <br /> I.Type of Buildi : (check one) ❑Village <br /> W 1 or 2 Family Dwelling-No.of Bedrooms: 3 <br /> 13Public/Commercial(describe use):_ ;R Town of <br /> ( 7 <br /> ❑State-Owned 0100 a I ver <br /> NearestRoad <br /> C.!'4i* iJJbLJ &K, <br /> Parcel Tax Number(s)U., <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. N Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued Sanitary Permit was previously issued <br /> IV.Tf pe of POWT System:(Check all that apply) <br /> ❑Non-pressurized In-ground PLMound ❑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 /> 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 /> 1 gSCy U V0. LS IvZ. : C� j <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing / trete strutted <br /> Tanks Tanks �— <br /> �v ; <- Y loco <br /> C' s x ❑ ❑ ❑ <br /> VIII:Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Pluis Signatur (no stamps): MP/MPRS No. Business Phone Number <br /> W (S 0ev r It �,�-� ZZ 'ZZ` 7i C;6- o <br /> Plumber's Address(Street City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issu' g gent Sig o stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee)4 ��r � ' <br /> Determination �D <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />