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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 See reverse side for instructions for completing this application PO BOX 7302 <br /> Department of Commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <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. state owned.) <br /> County State Sanitary Permit Number <br /> tom' ck if vision to revio plication State Plan 1.D.Number <br /> 58932Itl <br /> I.Application Information-Please Prin7all <br /> tion <br /> PropertyOwner N a Location: <br /> p Property Location c <br /> Pro r e N 5 l.) 1/4 Cl/4,S d Tap tl <br /> party Owner's Mailing Address � N,R (or <br /> �.►� �� Lot Number Block Number <br /> City,State Zip Code <br /> Be.4�ek Phone Number Subdivision Name or CSM Number <br /> II.Type of Building: (check one) <br /> ly 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑City <br /> ❑Public/Commercial(describe use):_ ❑Village <br /> P"Pown of / <br /> ❑State-Owned d�S�j N C <br /> Nearest Road <br /> Parcel Tax Numbers) <br /> III.Type of ermit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1• ew 2. ❑Replacement 3. ❑Replacement of 4. <br /> System 5• 6. ❑Addition to <br /> B) Y System Tank Only <br /> Permit Number Existing System <br /> ❑A Sanitary Permit was previously issued Date Issued <br /> IV.Type of POWT System: (Check all that apply) <br /> PkNon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank <br /> 13 At-grade ❑ <br /> ❑Single Pass Drip Line <br /> ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.DispersaUTreatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Pe;Crete <br /> Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft. <br /> ) (MinElevation <br /> VII.Tank Capacity in Total #of Manufactwer Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- <br /> New Existing structed glass <br /> Tanks Tanks <br /> i C DOD -- DUO <Jr—A c� ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> [:::- <br /> Name(pri Plumber's Signature(n tamps): MP/MPRS No. <br /> - - j /�� 41 D Business Phone Number <br /> Plumber's Address(Street City,State,Zip Code) �oCt— G 7 <br /> B o'< S/5/ S/O e-N 7� <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwat=Dialiticilssi Isi ge Signa o stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee)Detemtination I 1 660 � � <br /> AVF <br /> X.Conditions of Approval/Beasons for Disapproval: <br /> SBD-6398(R.07/00) <br />