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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 /> `IseonsinSee reverse side for instructions for completing this application PO Box 7302 <br /> Department or Commerce <br /> Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form rocounty if state owned.) <br /> Attach complete lana to the coup co only)for system,on r not ass than 8-I/2 x i l inches in size. r <br /> Spee Sanitary i O ❑ if ian0W icus a p' ation State P1 I. V I <br /> L APplicadon Information-Please Print all hiformation Location: <br /> Property Ow°°r Napte C Property Location ? <br /> p(/ 1/4 I/4 7 T.� ,N RAyE joa W <br /> Property Owner's Mailin Address 6et-�scr Block Number <br /> 1,/9 14-oe Z_ <br /> City.State Zip Code Phone Number Subdivision Name or CSM Number <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No,of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): ;Q7o n of <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Ne <br /> m2'' <br /> A) 1. ❑New System 2. Replacement 3. ❑Replacement of 4. ❑Addition to ParceCl TTaax Number(s) <br /> System Tank Only Existing System D O .:1 / O <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of P'OWT System:(Check all that apply) <br /> ❑Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground *NWolding 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 Ates 3.Dispersal Area 4.Soil Application S.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(GalsJday/sq.R) (Min./inch) Elevation <br /> 3dc> � <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 Tanks <br /> nJ 00lJ LbD � �'f/u� qr' ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I the undersiRned,assume MMionsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) /•// Plumbees Signature(no s): MP/MPRS No. <br /> r q Business Phone Number ry <br /> Plumber's Address(Street,City,State,Zip Code) —7 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing gent Signature(No stamps) <br /> LApproved ❑Owner Given Initial Adverse Surcharge Fee)Determinationonditions of Approval/Reasons for Disapproval: <br /> SBD-6398 807/00 <br /> SNE 1 <br /> ?pNN ( <br /> �jNr <br />