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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W. Washings <br /> See reverse side for instructions for completing this application PO Box 2 <br /> `aseonsin Personal information you provide may be used for secondary purposes Madison,WI 537 <br /> Department of Commerce Y P Y ry pu ores <br /> [Privacy Law,s. 15.04(t)(m)) (Submit completed form to coun 11t <br /> state o J <br /> Attach com tete plans to the coun co only) the system,on er not less than 8-1/2 x 1 I inches in size. �. <br /> County State Sm Pe a N r heck,i[rev ipn 4t reous application State Plan[.D.Number <br /> L A ication Information-Please Pri t alf Information Location: <br /> Property Owner Name Property Location <br /> T/ 1&eirg 1/4 1/4,S i"1 T* ,N.I E (or JO <br /> to e�{rty Owner's Mailing Address LotNumberBlock Number <br /> City,State Zip Code Phone Number <br /> Subdivision Name or CSM Number <br /> QQ46�71ef' )l/1 N 6-5-44031 ( 5-0-7 )017-06q? 6037 Iq G-es <br /> II.Type of Building: (check one) ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): CrTown of <br /> ❑ State-Owned 5U-i"15J <br /> III. Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road 26 �� <br /> A) I. 49 New System 2. ❑ Replacement 3. C3Replacement of 4. ElAddition to P reel Tax Numbe(s <br /> System Tank OnlyExistingSystem <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> TV.Type of POWT System: (Check all that apply) <br /> ANon-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 /> day 959 66 7 qG 6 <br /> VI.Tank Capacity in Total i#of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> IPA 1716p — ,1z50 ( %aw k� ❑ 13 ❑ <br /> ❑ ❑ Cl ❑ ❑ <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 stamps): 1 MP/MPRS No. Business Phone Number <br /> umbers Address(Street,City State,Zip Code) <br /> 2.7760 3-< LV I- _54-$q:3 <br /> VIII. County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issw��Agent <br /> tSSignature(No stamps) <br /> i <br /> oved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determinationao�' <br /> 7 <br /> IX. Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R071100 <br />