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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> Vis consin personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [privacy Law,s. 1 be used <br /> for <br /> (Submit completed form to county if not <br /> state owned. <br /> Attach completc plans to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> Count Sanitary Permit Number <br /> e T � revious application State Plan I.D.Number <br /> ;Cr i' <br /> revision t <br /> Ot <br /> I.Application Information-Please Print all Informatio Location: <br /> 3perty Owner Name�_'/]�) L L/ Property Location're.4 �7 T/Ylvr e1/4SLC4/4 ST? ,N I/� <br /> � o W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> F 0 /S 3 <br /> City St Zip—Code Phone Number Subdivision Name or CSM Number <br /> ule S7- f3 1r <br /> II.Type of Building: (check one) ❑city <br /> 1 or 2 Family Dwelling-No.of Bedrooms: =:2, ❑Village <br /> ❑ Public/Commercial(describe use): PKTown of <br /> ❑ State-Owned r y t ee et &Yi <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nest Rtod s <br /> � El LiE <br /> - p I <br /> A) 1. New System 2. ❑Replacement 3. ❑Replacement of 4. Addition to Parcel Tax Numbers) F d <br /> System Tank Onl) Existing System ( — 33/7-0-L- 00 <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> VfAt-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 S.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.R.) (Min./inch) Elevation <br /> 3©o Izq Zq %9, / 00 .7*7 <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 structed <br /> Tanks Tanks <br /> rL 1000 QJ11 ❑ ❑ ❑ ❑ <br /> &00 ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume res onsibili for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(point) Plu er's Signature o ps): MP/MPRS No. Business Phone Number <br /> PSS ref 2-2J_27 7 17/S- 67 <br /> Plumbers Address(Stree/t,_City,State,Zip Code `/ //Q('�//� / / / cK(� <br /> Vnty/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issum gent Signa stamps) <br /> d ❑Owner Given Initial Adverse Surch ge e) /Determinationtions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />