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SSafety&Buildings Division <br /> Sanitary Permit Application <br /> 201 W.Washington Ave. <br /> In accord with Comm 83.21,Wis.Adm. Code PO Box 7302 <br /> �. See reverse side for instructions for completing this applicationL(Submit <br /> Madison,WI 53707-7302po county <br /> `isconsin Personal information you provide may be used for secondary purposes completed form tif not <br /> Department of Commerce [Privacy Law,s. 15.04(I)(m)] <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 p _ State Sani Permit Number ❑Check if revision to previous application State Plan 1 D.Number <br /> a PIV 2 12,3 xtp C <br /> I.Application Information-Please Print all Information l(n # Location: <br /> Pro <br /> Owner Name Property L�ocation <br /> F� qN / <br /> ( At J e, A Q� L' �l/4,v� 1/4,S/5-/7f ,)C E(o <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code �Phonc Subdivision Name or CSM Number <br /> wT- s-Y�93 �-- <br /> �II,.Type of Building: (check one) City <br /> � L I or 2 Family Dwelling-No.of Bedrooms: 2— ❑Vil a of <br /> • ❑Public/Commercial(describe use):_ �_ <br /> ❑State-Owned <br /> Nearest Road <br /> S�a^' e <br /> Parcel Ta�N <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) placement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Pert Number Dale Issued <br /> ❑ miA Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground OAound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.DispersaVTreatment Area Information: <br /> L Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevafton 7.Final Grade <br /> Required Proposed Rate(Galslday/sq.ft.) (Min./inch) Elevation <br /> 3ey 5:�l 300 36/ , s 98. -7 <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 /> Tic 7 Sp 73 <br /> Sa�S -- Sad - � ❑ ❑ ❑ ❑ <br /> V II.Resp nsibility 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 /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> J ❑Disapproved Sanitary Permit Fee(Includes Groundwater T Date Issued Issuing Agent Signature(No stamps) <br /> C3(Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> ��/y�`� 1 n--ia-aq <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R 07/00) <br />