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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 /> Asconsin See reverse side for instructions for completing this application PO Box 7302 <br /> 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 pap not less than 8-1/2 x 11 inches in size. <br /> Coun State Sart Permit Number ❑Che i revi 'on to previo application State Plan I.D.Number <br /> c��^A) c. <br /> I.Application Information-Please Pri t all Information Location: <br /> Property Owner Name Property Location <br /> c) -5,"'IJ 0 A-.), Sec'114711Ci4,s�7r S'o,N,RAE <br /> e—. SIJ r <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number/ <br /> /ale rr�•J r63� � T fovrl <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ �4'own of�- <br /> ❑State-Owned v ^C k S Cry <br /> Nearest Road <br /> �Ag le S <br /> Parcel Tax Num er(s) 90 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ew 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 /> rc 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.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 /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 35 9 : l �7•�' <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New T Existing crete structed <br /> Tanks I Tanks <br /> p_ f + ❑ ❑ ❑ ❑ <br /> ic �70iJ 0 r <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(pri t) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> /1`0 21 S/ Ys i^ e •-J a S— 8 7--2— <br /> IX <br /> IX.County/Department Use Only <br /> �� ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin gent rgnature(l i <br /> O"Approved 1 ❑Owner Given Initial Adverse Surcharge Fee) <br /> OD b <br /> Determination 40%X, 46- <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />