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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 /> �� <br /> See reverse side for instructions for completing this application PO 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 /> Con" /W e- State Sanitary Permi Numllcr C c if revon to previo application State Plan I.D.Number <br /> I.Application Information-Please Print all In o oration Location: <br /> Prop e Owner Name <br /> y+� Property Location ' <br /> O I e-r 1 f� e 1/4 1/4,S T3�N,R/' (or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> a 7'� f zEE d 6,L ; 4/ <br /> City,State Zip Code Phone Number <br /> ,00er GroUe k 14, 5-5-0 7 7 � V -2/ 4 /2 ? <br /> II.Type of Building: (check one) ❑city <br /> )W-- 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ 9°fown of <br /> ❑ State-Owned /R-C,0 Ile- <br /> Nearest <br /> /fi <br /> Nearest Road <br /> y Cr,4W6 rr IN1�/3' <br /> Parcel TY ei c7 7646 <br /> ax umber s <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. DFReplacement 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 /> (, 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 Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <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 /> S!,-04< DOv DOd arwesco ❑ ❑ ❑ ❑ 'u— <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) Plum er's Signature o stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ,Boa- s�y .s'i•^�•� .�� s5'8'7� <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Pe r Fee(Includes Groundwater Date Issued Issuing a Sign (No s <br /> pproved 13Owner Given Initial Adverse Surcharge F <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />