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I �t <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> ` �sCOns'n See reverse side for instructions for completing this application PO Box 7302 <br /> Department of commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> [Privacy Law,s. 15.04(I)(m)) (Submit completed forth to county if not <br /> state owned. <br /> Attach complete plans to the coup co only)for the system,on paper not less than 8-1/2 x41 inches in size. <br /> County Sta�Sanitary Permit ❑Check if revision to revio s ap lication State'PI I.D Numbel <br /> 1 r, 9H !Md a*J <br /> I.Application Information-Please Print all Information <br /> Property Owner Name Location:t Property Location +. <br /> ks <br /> O '1/4 I/4,S 3TY�,N,IZ'• or <br /> Property Owner's Mailin�g Address / ^ Lot Number Block Number <br /> G/ LO( oZO G , . <br /> City,,State Zip Code Phone Number Subdivision Name or CSM Number <br /> II.Type of Building: (check one) ❑City <br /> PL-,1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): ,FtTown of <br /> ❑ Il$tate-Owned rj O l <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road n <br /> C_6 <br /> A) 1. ❑New System 2. Replacement 3. ❑Replacement of 4. ❑Addition to Pa cel Tax Number(s) <br /> System Tank Only Existing System G a3 6 7 a <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV. 'Type of POWT System: (Check all that apply) <br /> ❑Nbn-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pgqessurized In-ground ,ElVolding Tank ❑Single Pass ❑Drip Line <br /> ❑ rade ❑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 /> VI.`Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> InfoIrmation Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII Responsibility Statement <br /> I,the undersi med assume res onsibili for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Innt) Plumber's Signature(no pps): MP/MPRS No. Business Phone Num <br /> I ber <br /> �d G� �l ��7G � �72�� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> I <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent Signature(No stamps) <br /> Ipproved ❑Owner Given Initial Adverse Surcharge Fee) / S l i /� OD <br /> Determination h ( l p i <br /> IX.(Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />