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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,WI 53707-7302 <br /> Department of Commerce [Privacy Law,s. 15.04(l)(m)] (Submit completed form to county if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the s tem,on paper not less than 8-1/2 x 11 inches in size. <br /> Counqt State Sanitary Permit Number ❑Che rc i vis onto reviou plication State Plan L D.Numbe <br /> urne <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location j <br /> A1�1/4 /4,S (p T N,li or W <br /> Property is Mailing Address Lot Number Block Number <br /> T, 6. ' <br /> G 01 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> o am vs - � <br /> II.Type of Building: (check one) ❑city <br /> O1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> Public/Commercial(describe use):_ [Town of <br /> ❑State-Owned <br /> Nearest Road <br /> Parcel Tax Numtk-330&-03*6 <br /> II1.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. jK 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 /> ITSNon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> �j 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 /> V5-0 44#z? ".3 17 1 4 '�, v q Y. 7 <br /> VII.Tank Capacity in TotalLTamnks <br /> Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons GallonCon- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> ❑ ❑ ❑ ❑ <br /> so -f-« t�O1eSer <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibilil for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) PI",e1rrLA--tJ er's Signatu (no ps): MP/MPRS No. Business Phone Number <br /> 0 -6stis <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 w <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fe (Includes Groundwater Date Issued Issuing A nt Signature s) <br /> %Approved ❑Owner Given Initial Adverse Surcharge Fee) r) <br /> 6 f <br /> Determination W` �a <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R 07/00) <br />