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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> N iseonsinSee reverse side for instructions for completing this application PO Box 7302 <br /> Department of Commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> (Privacy Law,s. 15.04(1)(m)] (Submit completed forth to county if not <br /> state owned. <br /> Attach complete laps to the countyco only)for the system,on a r not less than 8-1/2 x 11 inches in size. <br /> County State Salo e 't Number ❑ eck if f vision to previ us application State Plan L D.N ber <br /> I.Application Information-Please Prin ll Information Location: <br /> Property O net Name Property Location <br /> /hp �ishbo(c�l, c. � sE sLO /4 <br /> ` <br /> Property Owner's Mailing Ad cess 1/4 1/4,S T P,N,R'ko W <br /> 5e7�q Lot Number Block Number <br /> t60 3���7 a <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> VA <br /> nl W► 548? �s� ti. • 5V <br /> II.Type of Building: (check one) ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Be oom �.t +� ❑Village <br /> 0 Public/Commercial(describe use):,M- R�Cd% �cI•!p X 0 X 0 °W"°e'I ,�55 <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road 77 <br /> A) I. _*ew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> S stem Tank Only Existing System t)3 -53 _Q_700 <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> I!/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 /> Required Proed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> � po <br /> ' ° ( `f8 . .S' -� q7o qq.o <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 /> L 1�t7 l' IGY� I D,rtpJsco ❑ ❑ ❑ ❑ <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(print) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number �/ <br /> 94 <br /> �S4 S — ��/ <br /> umber's Address(Street,City State,Zip Co e) <br /> 277(00 3S (n7£BSTEK WI. 54$83 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date sue Issuing A en WSignayr!, o ) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> n�I <br /> Determination W <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />