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V <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> PO Box 7302 <br /> See reverse side for instructions for completing this application Madison,WI 53707-7302 <br /> VisconSin <br /> Personal information you provide may be used for secondary purposes (Submit completed form to county if not <br /> Department of Commerce (Privacy Law,s. 15.04(1)(m)] <br /> state owned. <br /> Attach complete plans to the county copy only)for the system,on p!ger not less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Pe it Number ❑ eck if r vision to pre 'ous application State Plan I.D.Number <br /> 7 <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> �- � Qm`o / 1/4 1/4 S/BT ,N,12!yE or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> /o Z 9 z So f1\ "+u e Croarr 4r <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Lvc, 4i S-VeS3 44j^j + _Sct4hre Sv <br /> Il.Type of Building: (check one) Li City <br /> ,M 1 or 2 Family Dwelling-No.of Bedrooms: Pff❑TowVillan of <br /> ❑ Public/Commercial(describe use): <br /> ❑ State-Owned tic <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Near R' re Lq e <br /> A) 1. X1New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) G <br /> System Tank Only Existing S stem S— 90 S6 —� o <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System: (Check all that apply) <br /> QKNon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground 13 Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 76.Sys;tem Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> Sod (4ao Cc � 4 S s a 971J <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 /> ❑ ❑ ❑ ❑ <br /> t <br /> jpo (26 M Ao <br /> VII.Responsibility Statement <br /> I,the undersigned,assume res onsMflulss�lgnn <br /> llation of the POWTS shown on the attached plans. <br /> Plumber's Name(print os ps): MP/MPRSNo. Business Phone Number <br /> cb�rT 1\ -,r /,o /336 <br /> Plumber's Address(Street,City,State,Zip Code) _ h <br /> Z //��� S � o1rCj6?r.0 <br /> VI I.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing gent Signature(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />