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;20 ewxyw <br /> 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 15 Box 7302 <br /> `4sconsin 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 /> County State Sanitary Pe it Number heck teif vision to prevw us application State Plan 1.D.Number <br /> . a Sa <br /> I.Application Information-Please Prtfit all InIonriation Location: <br /> Property Owner Name Property Location r <br /> Soot) 6,50 1/4 1/4 S T 1 N, JE o W <br /> Property Owner's Mailing Address r,.t NT—h— Block Number <br /> 511* PFINX PO4W 1�D- _ S <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> It R N• 5.50$2 (5i00 V. /7 P- 190 <br /> lI.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: Z ❑Town of <br /> Village <br /> ❑ Public/Commercial(describe use): `grown of C <br /> ❑ State-Owned �u <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) rNearest Road <br /> A) t. �I New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to lLT�Numbers) O,S stem Tank Onl Existin S stem <br /> B) 1 Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> 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 /> — <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 /> 300 42m r.7 --- 957 .6 <br /> gs. <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 /> OLID jhbxkoo ❑ ❑ ❑ <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(nos ps): MP/MPRS No. Business Phone Number <br /> • ,;,L,.,,1 <br /> lumber's Address(Street,City,State,Zip de) <br /> 27760 ff -V A&Wz W . S4873 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Perini[F (Includes Groundwater Date Iss ed Issuin nt Si a s mps) <br /> proved 13Owner Given Initial Adverse Surcharge 0 <br /> Determination 1�/ <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />