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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 /> Visconsin <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [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 /> Coun State S i Permit Number Q Check' revision to previous application State Plan 1.D.Number <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name / Property Location G q <br /> dd z)'9— f? '�L f ClA54! 1/4,S,7,Z T3 ,N,R"?(or <br /> Property Owner's Wiling Address <br /> // p Lot Number Block Number <br /> er6 <br /> yg"69 odeC-)� <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> G r +015 Cu w:r <br /> Il.Type of Building: (check one) ❑city <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ PlEown of <br /> ❑ State-Owned �/g- '/"/'"/ <br /> Nearest Road <br /> SOe/e-/'I e-C�k,- <br /> Parcel Tax Number(s) <br /> o Shea <br /> I1I.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. PF New 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> Dion-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 Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> ySo Y3 y� -- l�S 2 y'7. 0 <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 /> c <br /> let)C) — laod ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.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 o stamps): MP/MPRS No. "uussiiness Phone Number <br /> Aj c�(e- <br /> A- leLittIM (�4 r.� 02 l 4 Y1 —'Z�s" <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing n gnatu o stamps) <br /> k 1Approved ❑Owner Given Initial Adverse Surcharge Fee)Q ,rn f`/lnf `q <br /> Determination (' (J U r r <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />