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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 Submit completed form to <br /> [Privacy Law,s. 15.04(1)(m)] ( P county if not <br /> state owned. Qj <br /> Attach complete plans to the coon co onlyfor the s stem,on a er not less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Pennit Nu ber ❑C ck if revision to previous plication State Plan I.D.Number 1,1 <br /> I.Application Information-Please Print all Inform ion O Location: V <br /> Property <br /> Ay Owner Name Property Location .Oc/ <br /> '4 C//j ,Sa T ,N, or <br /> Property Owner's Mailing AddressLot Number Block Number <br /> City,StateZip Code Phone Number Subdivision Name or CSM Number <br /> rred-e r. C 551837 <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: Z ❑Village <br /> ❑ Public/Commercial(describe use): FTown of/ <br /> ❑ State-Owned r /Tale_ A,%kc <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road e, <br /> A) L ❑New System 2. {Replacement 3. ❑Replacement of 4. ❑Addition to Parcel 76.Numbers) <br /> S stem Tank Onl Existin S stem Q 3 y / s146� 0 -3 Od <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground g 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 /> 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 /> d��r�+ ODU DDO , ��� ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached lans. <br /> Plumber's Name(print) // Plumber's Signature(no stamps): MP/MPRS No. cy Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> '20'k s% Sime G.J S �7' <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin gent Signature(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination 0 <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />