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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 /> Visconsin See reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for secondary purposes Madison,W153707-7302 <br /> Department of Commerce [Privacy Law,s. 15.04(l)(m)] (Submit completed form to county if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)for tlisystem,on paper neqess than 8-1/2 x 11 inches in size. <br /> Count�Y5 e Stated V Permit Number ❑C c if revisjon to previous ap lication State Plan 1.D.Number <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location C-- <br /> b,r//1`I,) -S c4- / O E1/4X) 1/4,SIYT-T ,N,R/E(or <br /> Property Owner's Mailing Address Lpt Number Block Number <br /> w : 3 /005 , 70 3 <br /> City,State ip Code Phone Number / or CSM Number <br /> S o Z,^) Q- f i,-) s_v ( )&,t�S-75:Z7 V/ /q 3/"-V/ <br /> Ir Type of Building: (check one) ❑City <br /> C6- 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ PKTown of <br /> ❑ State-Owned �N S 4 <br /> Nearest oad <br /> Parcel Tax N be s) -0aa �a O <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. QlfNew 2. ❑Replacement 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 /> ly.Type of POWT System: (Check all that apply) <br /> JILNon-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.DispersaUTreatment 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 /> 3�0 y�? el y3 ?- .17 y5/, 7 <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New LTanks <br /> crete structed <br /> Tanks odoDori tit9 ra)ej C C> ❑ ❑ ❑ ❑ <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(p nt) I Plumber's Signature o stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> / ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issui Age ign (No stamps) <br /> IZApproved ❑Owner Given Initial Adverse Surcharge Fee) j/��+ /D� <br /> Determination �Q /, tM <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />