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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 /> See reverse side for instructions for completing this application PO Box 7302 <br /> Visconsin Personal information you provide may be used for secondary purposes Madison,W153707-7302 <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. 00 <br /> CountyState Sanitary Pe t Nymber ❑C ck if reyjsion O previo application State Plan I.D.Number <br /> 4e 74 <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> - <br /> 4<- <br /> - , rw0A) le- 110 Z `e. bd[CJ �IA FRN//E , , , E(o <br /> Property Owner's Mailing Address Lot Number Block Number <br /> r <br /> eoll 3 a S Vv r S ,e-. .— <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> rrigl/e in .J 7:5'`/3 Z ( 7/5 >s7!-/ 3s"y <br /> II.Type of ilding: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑Public/Commercial(describe use):_ P14own of <br /> c <br /> ❑State-Owned S S <br /> Nearest Road <br /> Parcel Tax Number(s)03q- <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) -f <br /> A) 1. w 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <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 /> l / Required Proposed Rate(GalsJday/sq.R.) (Min./inch) // Elevation <br /> S4 r? 7 6rYSr , 7 �' /174 <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 /> Sle-6 c Da D -- OOv S �i9�/ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's N I Plumber's Signaturestamps: MP/MPRS No. Business Phone Number <br /> ZA)At/ `.y, IGr/� Zz 7,9 T c.7Y9'-?26 <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 ignature stamps) <br /> LL7 Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination N S t//1LIL <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />