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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> Asconsin personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce Submit completed form to <br /> [Privacy Law,s. 15.04(1)(m)] ( P county if not so <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 State,Sanitary�mirt Number ❑ heck if revon to pre ' s application State Plan I.D.Number <br /> urHe 1l LL37 Y <br /> I.Application Information-Please Print all Information Location: I <br /> Property Owner Name� > Property Location <br /> 1 Y uS o e cop1/4/v4/4,S21 N,dfE(o W <br /> Property Owner's Mailing Address <br /> Lo[Number Block Number <br /> 2sgq s Ie <4 -. <br /> er m <br /> City,state Zip Code Phone Numb <br /> r Subdivision Nae or CSM Number <br /> G. ire k,s �l, s`F a <br /> II.Type of Builth : (check one) ❑City <br /> 0 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ ISTown of <br /> ❑ State-Owned <br /> Nearest Road C f to �1P.a <br /> Parcel Tax Number(s)6 O ,,( O[ <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 /> J[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 /> o'7 <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 I Tanks <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibil'ty for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) PI mber's Signa re( stamps): MP/MPRS No. Business Phone Number <br /> NIC(s K0 �--, 2z ZZLj 7rS 6,@;or <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issui a stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) 1J � �� <br /> Determination �+¢r( <br /> X.Conditions of Approval/Reasons for Disapproval: MA <br /> NG V/V7), <br /> SBD-6398(R.07/00) <br />