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Sanitary Permit Application Safety&Buildings ly�l <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washing[ ve. <br /> � See reverse side for instructions for completing this application PO Bo <br /> Nvi� seonsin Personal information you provide may be used for secondary purposes Madison,WI 53707 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to coun not <br /> stateCaMn <br /> Attach com tete plans to the county copy only)f e system,on papq not less than 8-1/2 x I 1 inches in size. <br /> County State Sanit a ber Mkif revision to revio s application State Plan I.D.Number <br /> I.Aplillcation Information-Please Pri t all Information Location: <br /> Property Owner Name Property Location I <br /> DWE O I/4 I/4,S T ,N, bE or W <br /> PropertFOwnees Mailing Address Lot Number Block Number <br /> S LQA&Ms GK gv <br /> City,State Zip Code Phone Number Subd'vision Name or CSM Number <br /> 48'nt� rs' 35 <br /> II Type of Bui ing: (check one) 13 City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: _55 <br /> 13 Village <br /> ❑ Public/Commercial(describe use): own of//�, <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Neares Road <br /> A) 1. .;KNew System 2. ❑ Replacement 3. ❑ Replacement of 4. ❑Addition to arcel Wx Number(g)_ _ <br /> S stem Tank Onl Existin S stem ��' <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> :PMqon-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.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 1 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Requi d Propos d Rate(GalsJday/sq.ft.) (Min./inch) Elevation <br /> � �¢5 7� . 7 q¢o f�. o <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 /> E 000 l nov 1 wnnW.'�Sco ❑ ❑ ❑ ❑ <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(no stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,CState,Zip Code) <br /> 2-7710.0 ity3S W£85TEK l,Jl. 54 893 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Igcludes Groundwater Date Iss d Issuing Agent$ign tore ) <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee) j(Q�`) 16,00 6 r00 /! <br /> Determination !F7 <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />