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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 <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 [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 ❑Cheeck if revi on to revious plication State Plan 1.D.Number <br /> Err E y a� <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> �E['.e O �1/1/4 Ae /4,S IsT 1,N,Vf'(o <br /> Property Owner's Mailing AdUress Lot Number Block Number <br /> Z5!5-23 ern,'/e r� f 7/ <br /> City,State <br /> ` Zip CodePhone Number Subdivision Name or CSM Number <br /> F7JW5c/9�e ( 11� ) Z5Y+ ?11� N/w .5pl,aJlj <br /> 71� <br /> II.Type of Building: (check one) ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: Z ❑Village <br /> ❑Public/Commercial(describe use):_ )&Town of <br /> ❑State-OwnedC�C <br /> Road <br /> Parcel <br /> %Zo b 9Llr000 5/2-Me,-$5 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. 0 New 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> $) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> A Non-pressurized In-ground d ❑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 /> I.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 /> 31!)Z5 93: 3 3 �S z <br /> VII.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 I Tanks �r <br /> /r /Sd l Lv,` ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation o e POWTS shown on the attached plans. <br /> Plumb s/Name((print) Plumbe Sign e s ps): 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 Issuing A gnature ps) <br /> II/Approved ❑Owner Given Initial Adverse Surcharge Fee) �( n�O IN 7 / /��0 <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> 1 SAY - I <br /> 3UnNE7-T.COU <br /> NrV <br /> SBD-6398(R.07/00) <br />