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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 /> See reverse side for instructions for completing this application PO Box 7302 <br /> Visconsin of commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> [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 I State Sanitary Permit Number C eck if ision to previo application State Plan 1.D.Number <br /> 59O az. s <br /> I.Application Information-Please Print all Information Location: <br /> Prope Owner Name Property Location <br /> 1/4,S33T /6 <br /> Property er's Mailing Ad1/4 dress7 'f R E(or.12� <br /> Lot Number Block Number <br /> City,State Zip Code Phone Number 9;Qirisiex plane or CSM Number <br /> Zde1 few w -S-yg ( ) -7 V3 e a�8 <br /> II.Type of Building: (check one) 3 LiCity <br /> 1 or 2 Family Dwelling-No.of Bedrooms. ❑Village <br /> ❑Public/Commercial(describe use):_ _ `EKTown of <br /> ❑State-Owned 0 *k/AAj 0/ <br /> Nearest oad <br /> .sC9,ve- Gil -fe. <br /> Parcel Tax n, —73 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> FB) O <br /> 1. New 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> 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.DispersaVrreatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area T Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> �> V) <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 /> -�� J�ic DO -- �4� �/�i4-� ❑ ❑ ❑ o <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no ps): MP/M77PRS No, —7 9 BusinessyPhone Number <br /> Plumber (Street Ciy,State,Zrp odes � ` / 6" / ���� <br /> 11 <br /> ,do X S/ S'/ /t e--'J <br /> IX.County/Department Use Only <br /> ❑Disapproved I Sanitary Pemtit Fee(Includes Groundwater Date Issued jssumg!7Kj Signature <br /> f Approved ❑Owner Given Initial Adverse Surcharge Fee) ps) <br /> Determination 50 r <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />