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whhmd <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 PO Box 7302 <br /> ` SCOIfSin 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. 1 <br /> County State Sanitary P rmit er ❑C;he revisr n to previous pplication State Plan 1.D.Number l/ <br /> urrt-e*+ 8 a g� e7<7a <br /> I.Application Information-Please Print a 1 Information Location: <br /> Property Owner Name 'C/ /(�� lopPrroperrty Location / ^� R <br /> [ lM T `—� r ►� 4- IV^'1/4A /4,S(�Tz I,N,RILE(OCZ <br /> Property Owner's Mailing Addresi Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 15-Y qTok <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms:3 ❑Village <br /> ❑Public/Commercial(describe use):_ 19 Town of <br /> J / <br /> ❑ State-Owned bra C� �4. � <br /> Nearest Road A 44e <br /> Parcel Tax Number(s)03 .S'/S=O Ko0 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. PCReplacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Perini[was previously issued <br /> IV.Type of POWT System: (Check all that apply) �r <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.DispersaVrreatment 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(GalsJday/sq.ft.) (Min./inch) Elevation <br /> qyo <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing ( ,�__t 6O crete structed <br /> Tanks Tanks �-v <br /> l000 14L,Pr <br /> X ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibilify for installati n of the POWTS shown on the attached plans. <br /> Plumber's Name <br /> ber's Sign <br /> (p int) PI am (no ps): MP/MPRS No. Business Phone Number <br /> � e[S sir 22E22 �WT E6— 60 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit F (Includes Groundwater Date Issued Issuing Age igna s) <br /> #Approved ❑Owner Given Initial Adverse Surcharge Fee) 5o <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />