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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 /> Visconsin <br /> 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)forthe system,on pap not less than 8-1/2 x 11 inches in size. <br /> Co un f State S i Permit Number ❑ eck if ,vision to previo application State P I.D.Numbe n 1 <br /> t�YhCy' + �o� 9 Q <br /> I.Application Information-Please Print all Info mation Location: <br /> Property Owner Name i PropertyLocation <br /> VA 4 Nh, �0kYLS6r S61/k—X /4,S3ZT ,N,J9(o W <br /> Property Owner's Mailing Address Lot Number Block Num <br /> Assek,61%, �d <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> b w tt i ) q8,?-2-a <br /> II.Type of Building: (check one) ❑city <br /> PC 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ PI Town of <br /> ❑ State-Owned L(,100j el v-er <br /> Nearest Road k— SPm g <br /> Parcel Tax Number(s) RW <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. New 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <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 XMound ❑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 /> 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 (.l,,,6 — <br /> ) 6 GC to ❑ ❑ ❑ ❑ <br /> tl K 0(i K ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility r installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumb r s Signature o s ps): MP/MPRS No. Business Phone Number <br /> -2 (S o-v 2z zzq 7/S A6-9-60k <br /> Plumber's Address(Street,City,State,Zip Code) <br /> -7 T4 s 66 <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing gent Signature stamps) <br /> EH <br /> ❑Owner Given Initial Adverse Surcharge Fee) 11 ^�� co <br /> Determination 4O( <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />