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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 /> iseoinsin See reverse side for instructions for completing this applicati n PO Box 7302 <br /> Department <br /> Personal information you provide may secondary pu be used for seconds Madison,WI 53707-7302 <br /> f Commerce (Privacy Law,s. 15.04(l)(m)]oOsesIstmit completed form to county if not <br /> state owned. <br /> Attach complete plans to the county copy ci1 )for the system,on gaper not less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Permit Number ❑heck ifLVislon to revious application tat PI I D. umber �Jl <br /> I.ApAication Information-Please Print all Information 6 Location: <br /> Property Owner Name OQ <br /> Property Location <br /> O 5wa SR I/4 1/4,S ZI T ,N, o <br /> Property Owner's Mailing Address Lot Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> F11tZSII 54$ 15' 327-5745 <br /> K <br /> Type of Building: (check one) ❑City <br /> I or 2 Family Dwelling-No.of Bedrooms:_-+ ❑Village <br /> ❑ Public/Commercial(describe use): Town of �^yr„r <br /> ❑ State-Owned //'��11�f <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. ❑New System 2. Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Onl ExistingSystem _ 5� 61— 7 C-6 <br /> B) 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 XMound ❑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 /> Re uired Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> foo �o� �.0 1140 6.0 <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> C 1L 7.1zt 125D Zcoo Z- of ti' ❑ ❑ ❑ ❑ <br /> G JZSD 17sa 2- �kAH/ NrciCeezt' ° ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the PO WTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> umbers Address(Street,City State,Zip Co e) <br /> 27760 3S WE65TElZ Ldl- .548C13 <br /> VIll.County/Department Use Only <br /> ❑Disapproved Sanitary Permit fee(Includes Groundwater Date I sued Issuing t S' mps) <br /> proved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination Q,C [ ! <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />