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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> Vise6psin 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(1)(m)] (Submit completed form to county if not <br /> Attach complete plans(to the county copy only)for the system,on paper no less than 8-1/2 x 11 inches in size. state owned.) <br /> County State Sanitary Permit N mer ❑Check' visioft to previoass ap ication State Plan I.D.N ber <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name <br /> _ Property Location <br /> �I e�:v e-N.5L...> a ✓` / <br /> Property Owner's Mailing Address Lot Nlumber 1/4,S T /,tv,R A(o <br /> Block Number <br /> L3 _ <br /> Ci state <br /> City, Zip Code Phone Number Subdivision Name or CSM Number <br /> lvz 5 YP'7'2- ,asst ss�. s <br /> ( L34q r �.�3 <br /> II.Type of Building: (check one) 13 City <br /> 0-1 or 2 Family Dwelling-No.of Bedrooms: -Z ❑Village <br /> ❑Public/Commercial(describe use):_ 9aown of <br /> ❑ State-Owned eYi✓a <br /> Nearest Road C <br /> e 4. 5 <br /> Parcel Tax Nu ber(s) ..� <br /> III.Type of Permit: (Check only one box on line A. Check box on line if applicable) <br /> B <br /> A) 1. ❑New 2. acement 3. eplacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Date Issued <br /> ❑A Sanitary Permit was previously issued I <br /> Permit Number <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground ❑Mound ❑ Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground )OVolding 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 /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> iv c7D0 BOt) -2- <br /> 0 ❑ ❑ ❑ <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) Plumber's Signature trio stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved SanitaryPemut F-(Includes Groundwater Date Issued . Issuing Ag nt Si ture(No ps) <br /> *13 <br /> proved ❑Owner Given Initial Adverse Surcharge Fee) Ji <br /> Determination r� 9 Q <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />