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7 s ' <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> Visconsin <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce <br /> [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 the system,on paper not less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Permit Number 11Check if revision to previous application State Plan I.D.Number <br /> I.ApAcation Information-Please Print all Informat Location: <br /> Property Owner Name Property Location <br /> P} Q l/4 1/4,S p An,N,R or W <br /> ZPJ <br /> Property Owner's Mailing Address Lot Number Dlaek ititnber <br /> q11_7 51AP 01) P _ 3 G1 . 7 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> F_pIZIRIC 4 SS3 612 V. <br /> II.Type of Building: (c eck one) 0 City <br /> O1 or 2 Family Dwelling-No.of Bedrooms: 13 Village <br /> Public/Commercial(describe use): own of ^ <br /> ❑ State-Owned S <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> IR�1 rJ0 A <br /> A) 1. > 'J Iew System 2. ❑Replacement, 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(b. 4,,$OI z <br /> System Tank Onl3 Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> OkNon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ID Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 4So X43 64$ .� �-- qS 9 qa •d <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete sttucted <br /> Tanks Tanks <br /> s�. El ❑ 11 ❑ <br /> VII.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(n sta T MP/MPRS No. Business Phone Number <br /> IZOAADk/A/ 44ACl I 2.25 gS( <br /> Plumber's Address(Street,City,State,Zip C e) <br /> 2.7 (od ��� W 1 . 5�{•$�3 <br /> VIII, nty/Department Use Only <br /> ❑Disapproved Sanitary Permit F (Includes Groundwater Date Issued Issuing g Si s mps) <br /> Approved 0 Owner Given Initial Adverse Surcharge - <br /> Determination ! / " <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />