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On en <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> �� w See reverse side for instructions for completing this application PO Box 7302 <br /> `isconsin 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 not less than 8-1/2 x 11 inches in size. <br /> County Stnt�Sanitary Permit Number ❑ChePly if revision to pre - us application State Plan I.D.Number <br /> �f I.Appllication Information-Please Print all Information Location: <br /> Property Owner Name Property Location jLr <br /> 0144 WIMAQ> 1/4 1/4,S a5i N <br /> Property Owner's Mailing Address Lot Number <br /> 11m 6Lj5'NjQ1LV101< I a,c-i <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Kl►�� �. SS431 rs V. t . R '733 <br /> 1 Type of Building: (check one) 3 ❑city <br /> 1 or 2 Family Dwelling-No.of Bedrooms: Q Village <br /> ❑ Public/Commercial(describe use): Town of <br /> ❑ State-Owned lar <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road ,r <br /> A) 1. Iew System 2. El Replacement 3. El Replacement of 4. ❑Addition to I' cel Tare Num pber(st)� CPO <br /> �XJ I System Tank Only Exi tin&System f4tk, tld5 — <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> 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 /> 43 g 0 qs -o <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete sttucted <br /> Tanks Tanks <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.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 Signature(no stamp MP/MPRS No. Business Phone Number <br /> �r , 2SS5r7tS'-vL <br /> Plumber's Address(Street,City,State,Zip de) <br /> ?- 7(00 1,J! SIM <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent Signature(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) i'� 't <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: Aim - V <br /> Nj't40- 4U &0"A� <br /> SBD-6398 R07/00 <br />