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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,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 fort to county if not <br /> [Privacy Law,s. 15.04(1)(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 State Sanitary Permit Nu be,G ❑C k i�visio t;pre 'ous application State Plan L D.Number <br /> I.Application Information-Please Print all Information p Location: <br /> Property Owner Name/7' 7 a✓Property Location �?A),9— t4OM SO N 1/4 1/4 TY/ ,N,PJ <br /> YN,PJ E or <br /> PropeiYy Owner's Mailing Address Block Number <br /> 7.53 Tr A-Ford <br /> cty State / Zip Code Phone Number Subdivision Name or CSM Number <br /> Tf� .v S�/D 5 <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: a ❑Village <br /> ❑ Public/Commercial(describe use): l ¢Town of/,/ <br /> ❑ State-Owned IA " S r"J S 5 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. ❑New System 2. Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tats Number(s)d <br /> System Tank Only ExistingS stem 02- /Oa <br /> B) Permit Number Date Issued <br /> 13A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> KNon-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 /> RequireProposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> -30 o Y.;?,y 5'3�- , 7 �-- 9e, 6 �. <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 I Tanks <br /> /000 /Dao lJor4ie57cco ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(grin Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> oX 5'/ S//` L A-. , W S 41 svr 7:2— <br /> VIII. <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent S%nature(No stamps) <br /> XApproved ❑Owner Given Initial Adverse Surcharge Pee) <br /> X -P/15 D-0g �T <br /> ,` Determination I U (J <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />