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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 /> See reverse side for instructions for completing this application PO Box 7302 <br /> VLconsin 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 no ess than S-1/2 x 11 inches in size. <br /> County, e State SanitAW PermitNgmber ❑Chec if revis)pn to previous app'cation State Plan I.D.Number <br /> I.Application Information-Please Print all Information oS Location: <br /> Property Owner Name Property Location cc,,��" <br /> Ye r /e /!'1 1/4 1/4,S�� T37N,R/E(or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> a ;� ,2S' i,t, e 7'-, 1-2-5— <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 71-%� s So33 ( ) ,amt Lal�c t'61 ,005 <br /> Il.Type of ilding: (check one) ❑City <br /> 0, 1 or 2 Family Dwelling-No.of Bedrooms: -2 0 Village <br /> O'Town of <br /> ❑Public/Commercial(describe use):_ <br /> ❑ State-Owned .e 4�e j O <br /> Nearest Road <br /> /77, 77dCujxj <br /> Parcel© be s $`6 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. PLReplacement 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 /> 7 Awon-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 /> a Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> y.;zq 5'3z • 7 — 9s; y 97- 9 <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 I Tanks <br /> y� <br /> 5-e C) 0� ❑ ❑ ❑ ❑ <br /> VIII.Resp risibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(prin) Plumber's Signature(no tamps): MP/MPRS No. Business Phone Number / <br /> q1e 27L <br /> umber's Address(Street,City,State,Zip Code) <br /> 40 X .S—/ S/iA C <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date I sue Issuing A ent ps) <br /> 420-proved El Owner Given Initial Adverse Surcharge Fee�p w� 6 O v <br /> Determination __y (/v <br /> X.Conditions of Approval/Reasons for Disapproval: /dab <br /> CO <br /> SBD-6398(R.07/00) <br />