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Sanitary Permit Application Safety&Buildings Division <br /> 201 W.Washington Ave. <br /> In accord with Comm 83.21,Wis.Adm. Code PO Box 7302 <br /> `��� See reverse side for instructions for completing this application Madison,WI 53707-7302 <br /> -/sconSfn Personal information you provide may be used for secondary purposes (Submit completed form to county if not <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] state owned.) <br /> Attach complete plans(to the county copy only)for ystem,on pap of less than 8-1/2 x 11 inches in size. CI <br /> Court State Sani Permit Number ❑C c if rei to to ious pplication State Plan L D.Number <br /> u me 3 <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location p // <br /> �M/45�114,S Q T LT ON,R1 7(or <br /> Lot Number Block Number <br /> Property Owner's Mailing Address , O <br /> qD � Zi ode Phone Number Subdivision Name or CSM Number <br /> City,State p <br /> VVI n 5l0 0 ( So- > q3 -cD-1 ❑City <br /> II.Type of Building: (check one) ❑Village <br /> JM 1 or 2 Family Dwelling-No.of Bedrooms: 'Town of <br /> ❑Public/Commercial(describe use):_ <br /> krcel <br /> ❑State-Owned be )1G a IO` <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) 6. ❑Addition to <br /> 1:�B' <br /> 1. ❑New 2. Replacement 3. ❑Replacement of 4. 5Tank Onl Existing System <br /> System System yDate Issued <br /> ) Permit Number <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) ❑Sand Filter ❑Constructed Wetland <br /> 'Non-pressurized In-ground ❑Mound <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(Bp() 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) 9/ Elevation <br /> 3oD q,2 , ( Vrs es <br /> VII.Tank Capacity in Total F of Manufacturer Prefab Site HSteelFiber- Plastic <br /> Information Gallons Gallons Tanks ConCon- glass <br /> New ExistingCrete structedTanks Tanks <br /> ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibili for installation of the POWTS shown on the attached plans. Business Phone Number <br /> Plumber's Name(pri t) PI bees Signature MP/MPRS No. <br /> (S bY 21!E�-20&- <br /> Plumber's Address(Street,City,StateZip Code) <br /> S 2 r <br /> IX.County/Department Use Only <br /> Sanitary Permit <br /> ❑Disapproved Fe (Includes Groundwater Date Issued Issuin Agent Signature(No stamps) <br /> 3 pproved ❑Owner Given Initial Adverse Surcharge Fee) " <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />