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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 15 Box 7302 <br /> `VSconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce it completed form to county if not <br /> [privacy Law,s. 15.04(1)(m)] (Submcomp <br /> state owned.)t <br /> Attach complete plans to the county copy onlyWor the system,on paper not less than 8-1/2 x 11 inches in size. <br /> County Sta Sanit ry Permit Number Chec ifrevision <br /> S n to p vious application State Plan I.D.Number <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name / Property Location 6^e L, o <br /> S-k4e--n / e: A me,'�r 1/4 1/4 S/aT ",N,R/& or6> <br /> Property Owner's Mailing Address Lot Number Block Number <br /> Z SOO Qv-pAt/40 S>L <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> cv�` &<4 < �e ,a1�1 5S1/t9 �Si 9YLY £vc- <br /> P Ze, <br /> I ype of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms:� ❑Village <br /> 0&own of <br /> 10blit/Commercial(describe use): > <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> nSon <br /> A) 1. ❑New System 2. 1KReplacement 3. ❑Replacement of 4. ❑Addition to Parcel Talc Number(s) <br /> System Tank OnI3 Existing System o Z o - S/3/2 <br /> B) Permit Number Dale Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> rf Non-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.P <br /> .Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) __4 Elevation <br /> -'y fo <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installationofthe POWTS shown on the attached plans. <br /> Plum�b}is Name(//print/)^/ Plumber's rc(n tamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) r <br /> 11redef-tc e t <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin Agent Signature(No stamps) <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee) 4 aw V O_o <br /> Determination IF �O <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />