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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 /> V1.4consin See reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for second purposes Madison,WI 53707-7302 <br /> Department of Commerce ( )( )1 pmP Submit completed county[Privacy Law,s. 15.04 1 m ( p eted form to coon if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)fo the system,on paper n less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Pqnnit N berC eck if reyisiQn to previo s plication State Plan I.D.Number <br /> u ne�f 36 <br /> I.Application Information-Please Print all Information Location: <br /> Property <br /> LOwner Name Property Location <br /> VU-44 U414,S Z? N,R/k <br /> Property per's Mailing Address Lot Number / Block Number <br /> b *10 �� � a✓ 4of a— <br /> Ctb'. tate Zip Code Phone Number Subdivision Name or CSM Number <br /> 64a (?/s A6- (. 4fio " <br /> II.Type of Building: (check one) ❑City <br /> JKL 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ CKTown of <br /> ❑State-Owned W ee i4 pvl, <br /> Nearest Road P <br /> Parcel Tax Number(s)0j 330( <br /> Qa© <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> FB) <br /> I. ❑New 2. Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> Permit NumberDate Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground 01 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(Galslday/sq.ft.) (Min./inch) Elevation <br /> 1/_S_0 q�0 `1� t 100.Ss- oZ, 3 r- <br /> VIl.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing Gbm� crete structed <br /> Tanks Tanks jj�� <br /> cC. X000 J L' � ❑ ❑ ❑ ❑ <br /> 4 K (0()i) m ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibili for installation of the POWTS shown on the attached plans. <br /> Plumber'LNwnc(pr' t) PI tier's Signa[u (n tamps): MP/MPRS No. Business Phone Number <br /> 17t- 6- p <br /> Plumber's Address(Street,City,Stare,Zip Code) _I <br /> L g CJ In,. C3 <br /> ' ] .. <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Pennit Fe`y(Includes Groundwater Date Issued Issum gent Signature(No stamps) <br /> Kx1conditions <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee) ��� <br /> Determination <br /> of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />