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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^N e State 23 �ermit Number h k if rey�ionto�re ias application State Plan I.D.Number <br /> I.Application Information-Please Print all Information car Location: <br /> Property Owner Name fl <br /> Property Location J <br /> Ke i4/l e�/`Y/U ,k) 1/45 1-)1/4,S '3 T-72 N,It E(or W <br /> Property Owneft Mailing Address Lot Number Block Number <br /> o o?o 4 �j <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> sire.J W S-Ze ---" <br /> ( ) <br /> II.Type of Building: (check one) ❑City <br /> iif - 1 or 2 Family Dwelling-No.of Bedrooms:_0-117 ❑Village <br /> ❑Public/Commercial(describe use):_ 94own of <br /> ❑ State-Owned jlq-N i <br /> Nearest Road <br /> Parcel Tax Numb r(s) <br /> O r� <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑ASanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ANon-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 T Final Grade <br /> Required Proposed Rate(Galslday/sq.R.) (Min./inch) Elevation <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 Tanks <br /> crl�d j�ff 4./ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Pluum'ber's Name(p'nt) / Plumber's Signature(no 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 Agent Sign stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination �rJl)- U ZJ <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R 07/00) <br />