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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 /> � See reverse side for instructions for completing this application PO Box 7302 <br /> Nvi� scvnsin 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 <br /> state owned.) <br /> Attach complete plans(to the county copy only)for thgsystem,on paper nq less than 8-1/2 x 11 inches in size. <br /> Co State Sanitary Pe N her Ch f rev on jr,�previous lication State Plan I.D.Number ©� <br /> ,.9f p((D <br /> I.Application Information-Please Print all Informatioh Location: <br /> Property Owner NamerI / Property Location G <br /> �d� r��—/ l ed 1/4_5141/4,S Z/TyO,N,R1 E�/ <br /> (or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> a39 -7 o �'� /� — <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> S mo.N er Gr/;E- 5"Ygo / ( ) <br /> It Type of Building: (check one) ❑City <br /> ;24- 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> JKPttblic/Commercial(describe use):_ oµ1�/�/��� S aA 97, S' <br /> C&own of <br /> ❑State-Owned , S'c O <br /> Nearest Road <br /> au07D jB,,VA3,4GA <br /> Parcel Tax Numbers) / G O <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. Weplacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> OPlon-pressurized In-ground ❑Mound ❑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) 2 <br /> ` '60 Elevation <br /> VIL 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 I Tanks <br /> No ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <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(no stamps): MP/MPRS No. Business Phone Number <br /> 1 ) 4de- h`05lo/,n .a��6 3yy-7-a <br /> Plumber's Address(Street,City,State,Zip Code) <br /> '-J "G✓ .� <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuent Sign stamps) <br /> ) _L pproved ❑Owner Given Initial Adverse Surcharge Fee) � 6-,g-0-0\ r`1' <br /> Determination / <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />