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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 93.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> Visconsin 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 /> Co <br /> Attach com Iete plans to the county copy only)for the s stem,on paper not less than 8-1/2 x 1 I inches in size. state owned. <br /> Stale Sanitary permit r k if ision to prc�us applic tion State Plan I.D.Number <br /> n # 3� �o <br /> I.Application Information-Please Print all Information <br /> j R-12 <br /> Property Owner Name Location: (� <br /> ,. � � PropertyL�oycation 7 TJ p <br /> C. 'e lr; OV1 S` N,l� W <br /> Property Owner's Mailing Address <br /> Lot Number Block Number <br /> v � <br /> City,State Zip Code Phone Number <br /> Subdivision Name or CSM Number <br /> -�s W <br /> II.Type of Buildin : (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): XTown of <br /> ❑ State-Owned l V F y <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Neare OO <br /> oad <br /> A) I 1. ❑New System 2, l l Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Num O) �� <br /> System Tank Only Existing System 0 —4s, <br /> B) Permit Number Date Issued <br /> Cl A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> ❑Non-pressurized In-ground OMound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit <br /> ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application <br /> Required PP 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> 9 Proposed Rate(Gals./day/sq.ft.) (Min./inch) <br /> Elevation <br /> VI.Tank Capacity in Total I #of Manufacturer Prefab Site Steel Fiber- Plastic ' <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing <br /> Tanks Tanks Lo._ crete structed <br /> ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersi ed assume res onsibili for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(p 'nt Plu tier's Signature o s ps): MP/MPRS No. <br /> Business Phone Number <br /> A�e�S of l l-Q � �5�3 i r <br /> Plumber's Address(Street,Ci ,State,Zip Code) <br /> 7s_ Cori j. e�vs�-►- lt��r S X13 <br /> VIII.County/Department Use bnly <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Age Si o s <br /> proved ❑Owner Given Initial Adverse Surcharge Fee) Qd P) <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> S13D-6398 R07/00 <br />