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vE <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> Asconsin See 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 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 /> County N State,$ac7ia��reit Number ❑Ch if revision to previo application State Plan I.D.Number s <br /> I.Application Information-Please Print all Information Location: <br /> Property Own N e /'��/�- Property Location <br /> �� - 'I e W 1145;`'1/4,SZrT-?7N1 R'9(ortW <br /> Property Owner's Mailing Address Lot Number Block Number <br /> Be X' a 7.;2 <br /> City,State Zip Code Phone Number <br /> SG���!Q Subdivision Name or CSM Number <br /> S q <br /> �II Type of Building- (check one) ❑city <br /> l or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ �_ ' Town of <br /> ❑State-Owned �, lours'0'Y-'j J <br /> Nearest Road <br /> Parcel Tax Number(s)Z) _ <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> FB) <br /> 1. w 2. ❑Replacement 3. ❑Replacement of 4. 5. 6 ❑Addition to <br /> System System Tank Only Existing System. <br /> Permit Number <br /> Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> Ion-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 /> jO Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> G Y5 �-1-6) < 7 & 'e98- <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 structed <br /> Tanks Tanks <br /> 0 ❑ ❑ ❑ <br /> 68l] 10� �' ❑ ❑ ❑ ❑ <br /> V I.Resp risibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(pri t) Plumber's Signature(n stamps): MP/MPRS No. Business Phone Number <br /> 40 11,144-6 Z a ? S <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee i I ncludes Groundwater Date Issued IssuingAgcnt Signature(No stamps) <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee) Q q—j l ' <br /> Determination ] ] lel <br /> Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />