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Sanitary Permit Application Safety&Buildings Division <br /> ViSeonSin <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <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)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Permit Number ❑Check if revisi n to previo s a lication State Plan 1.D.Number <br /> CN <br /> I.Application Information-Please Print all In rmation Location: <br /> Property Owner Name Property Location <br /> A ' / 7 <br /> 1/4.5�1/4,553 T 37N,R E(or <br /> yc <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Sy8 -7 ( 7i3- )3Z 7- 81s3 <br /> II.Type of Building: (check one) ❑city <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ P'Town of <br /> ❑ State-Owned G d t-g <br /> Nearest Road / <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Parcel Tax Numbers) 1,4Y-0-O 'Y <br /> A) 1. ❑New 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. Addition to <br /> System System Tank Only E sting System <br /> B) PermitN ber Date sued <br /> gikA Sanitary Permit was previously issued a 3 8 6 6 <br /> IV.Type of POWT System: (Check all that apply) <br /> KNon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grl e ❑Aerobic Treatment Unit ElRecirculating ❑Other: <br /> adl -Y <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 /> 1 so z_ 9Z- 3 9s.o <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 sttucted <br /> Tanks I Tanks <br /> k 80o IT10�0)60 171 <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shownttached plans. <br /> /Ipmber's Name(print) Plumber's Signature( o stamps): MPR4ER_SNo. Business Phone Number <br /> LZ Z 8 L 'l'7Z- - <br /> lumber's Address(Street,City,State,Zip Co <br /> 16 /,5- ab 0 -Nl L) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing A t S' nat Ms <br /> Approved ❑Owner Given Initial Adverse Surcharge F ) t� <br /> Determination oC o' 7 b/d <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> l3 � ;� Q�r BI — WrOsn -313 <br /> 70,5- ti a 1 G ! <br /> SBD-6398(R 07/00) <br />