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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 /> See reverse side for instructions for completing this application PO Box 7302 <br /> Viseonsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <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. <br /> Co State Sanitary Permit Number Chec if revi ion to revious application State Plan I.D.Number <br /> I.Xpplication Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> R 1/4 1/4 St__ ,N,RJ or W <br /> Property Owner's Mailing Address Lot NumberBlock Nu er <br /> 3 i() 6ou <br /> City,State Zip Code Phone Number Subdivisio n Name or CSM Number <br /> rJ 5510 <br /> I�.Type of Building: (check one) ❑Citi' <br /> 1 or 2 Family Dwelling-No.of Bedrooms: Z ❑Village <br /> ❑ Public/Commercial(describe use): 1117own of <br /> ❑ State-Owned .TAC9.50 I <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. XNew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) ,�y/ <br /> System Tank Onl ExistingSystem — —C.10 <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> Type of POWT System: (Check all that apply) <br /> offNon-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 /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> Soo 4s2-9 432 .1 3 91 ,o q3 <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 /> Irl ❑ ❑ ❑ ❑ <br /> pimp omft L Sb ?5U <br /> 5v0 +1 ❑ ❑ ❑ ❑ <br /> VII.Responsibility 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 mps): MP/MPRS No. Business Phone Number <br /> umber's Address(Street,City,State,Zip C de) <br /> 211140 V J'5 W6� , W), 27-r893 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit F ncludes Groundwater Date Issued Issui ent Si afore ps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) r A <br /> 't1 Determination (J�(J <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />