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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 /> Visconsin <br /> Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of commerce <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> Attach complete plans(to the county copy only)for the system,on paperZot less than 8-1/2 x 11 inches in size. state owned.) <br /> CoWAVIIIAI el State Sanitary Permit Number ❑ e if rev-sion to previous plication State Plan 1.D.Number <br /> 5 o C7 C� GC <br /> I.Application Information-Please Print all Information Location: <br /> Property <br /> tyOwner Name C r Property Location P� <br /> r -'dAf(J1/4.5401/4,,V9T.3 ,N,R�E(o W <br /> O <br /> Property wner's ailing Address Lot Number Block Number <br /> Ci state <br /> ty, Zip Code Phone Number Suhdivicinn Name or CSM Number- <br /> IJ <br /> umber <br /> W4 �� w sr <br /> y9 -3 ( >���- Y�9-03 <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms:_C;:2 ❑Village <br /> ❑Public/Commercial(describe use):_ .2r7own of <br /> ❑State-Owned /07 e R-,.,U<9,-j <br /> Nearest Road <br /> -v 35— <br /> Parcel Tax N er(s) t r <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) I L ❑New 2. placement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number D Issue <br /> A Sanitary Permit was previously issued <br /> IV.Tye f POWT System: (Check all that apply) <br /> on-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 Application5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.R.) (Min./inch) Elevation <br /> -3a� Gov G d a s <br /> 771- 771 9X/ <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 /> 14 5e/ns"do So v / ❑ ❑ '� ❑ ❑ <br /> III.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signatu (no stamps): F,07 RS No. Business Phone Number <br /> A I -7--7-79-7 <br /> Plumber s Address(street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issui A t Signa o stamps) <br /> 1(Approved 11 Owner Given Initial Adverse Surcharge Fee) <br /> Determination So 2 �04 <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />