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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 /> Visconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed p eted forth 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 x I 1 inches in size. <br /> Coun�h7 State Sanitary Permit Number ❑Check if revision to repvious application S Plan I.D.Number <br /> JAG(�A! � Jr' �OgO — � O 3a t, 1� <br /> I.Application Information-Please Print all Information cation: <br /> PIprLy Owner Name,*//'�) IP perty Location0'r PAJ <br /> Propp /Owner's Mailing Address U 1/4 1/4,S33 T YON,R'E(or) <br /> wda- <br /> n / t Number Block Number <br /> 7 y2 7 da- �¢7L� <br /> /�Cii`ty,St/ate{ T/� Zip Code I Phone Number S CSM Number <br /> II.Type of Building: (check one) 0 City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> Public/Commercial(describe use):_ t1kown of <br /> ❑ State-Owned <br /> Nearest Ro <br /> Parcel Tax Number(s)y�33 <br /> IIl.Type of Permit: (Check only one box on line A. Check box on line B if applicable) h <br /> A) 1. ❑New 2. RFReplacemcnt 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ElA Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> Op 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.Percolation Rate 6.System Elevation 7.Final Grade <br /> -115-10 Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con. glass <br /> New Existing crete struct d <br /> Tanks Tanks <br /> cc <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Nameltl�54:�/71f7 <br /> ntPlumber's Signature no stamps): MP/MPRS No. Business Phone Number <br /> �z7� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Qd S/y Sirle, <br /> .-J <br /> IX.County/Department Use Only <br /> -/ ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing nt S' afore(N ps) <br /> OrApp <br /> ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R 07/00) <br />