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Sanitary Permit Application Safety&Buildings D 'on <br /> ViSCOn.Sin <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W. WashingtoSee reverse side for instructions for completing this application PO Bo Personal information you provide may be used for secondary purposes Madison,WI 537 <br /> Department of Commerce <br /> [Privacy Law,s. 15.04(I)(m)] (Submit completed form to coun t <br /> it <br /> state ) <br /> Attach complete plans to the county copy only)for system,on paper t less than 8-1/2 x I l inches in size. <br /> County State Sanitary P N eL if re .on to revious a lication State Plan 1.D.Number <br /> Cn <br /> 1.AppTication Information-Please Print al Information Location: <br /> Property Owner Name �/ / Property Location Q //J� I <br /> J-A 5 GRE/'IDAG 1/4 1/4,S 1 TTl/,N,RI1E o W <br /> Property Owners Mailing AddressL umber Block Numb <br /> I q300 81 S1_ l- I4 <br /> City,State Zip Code Phone Number Com. ubdivision Name or CSM Number <br /> II.Type of Building: (check one) ❑City <br /> ❑ l or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): Crown of u N(Dd <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) I.s lew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel lay Numb s <br /> System Tank Onl Existin S stem 0174 <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> on-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 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 /> 450 ¢� 7 96 ! 99 <br /> VI.Tank Capacity in Total i#of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> ❑ ❑ ❑ ❑ ❑ <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 /> &iAtW 11yFAaA1,5 <br /> Plumber's Address(Street,City State,Zip Co e) <br /> A-1760 -3,<- <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date I sued Issuin A nt Si o tamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge F Ur O� <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />