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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 /> isconsin See reverse side for instructions for completing this application PO Box 7302 <br /> Department of Commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> (Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> Attach complete plans(to the county copy only)fo a system,on paper not Tess than 8-1/2 x 1 I inches in size. state owned.) <br /> County State Sanitary Permit Number heck if re isio to previous a lication State Plan I.D.Number <br /> ;1e 383Co� , <br /> I.Application Information-Please Print all Information <br /> Property Owner Name LOCatiOn: <br /> 1� Property Location y <br /> Ci V-4-is rS Ov` /UGJ14AIE1/4,S Z I T�N,RI E o W <br /> Property Owner's Mailing Address <br /> t� Lot Number Block Number <br /> � (� <br /> City,State Zip Code Phone Number <br /> Subdivision Name or CSM Number <br /> II.Type of Building: (check one) <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑City <br /> Public/Commercial(describe use):_ ❑Village <br /> I$Town of <br /> ❑State-Owned ^ <br /> J.JQ N r f LS <br /> Nearest Road <br /> Parcel Tax Number(s) <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) 2 a <br /> J"B) <br /> I. ❑New 2. Replacement 3. ❑Replacement of 4. <br /> System System Tank Only 5' 6. ❑Addition to <br /> ermitNumber Existing System <br /> A Sanitary Permit was previously issued Date Issued <br /> IV.Type of POIA System:(Check all that apply) <br /> ,ft Non-pressurized In-ground ❑Mound <br /> ❑Pressurized In-ground ❑Sand Filter ❑Constructed Wetland <br /> ❑At-grade ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.DispersaVTreatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation Z Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft. <br /> S,> ) (Min./inch) Elevation <br /> CC:: �, y3 S-o ,7 `� 7 loo <br /> VII.Tank Capacity in Total #of Manufacturer <br /> Information Gallons Gallons Tanks Prefab Site Steel Fiber- Plastic <br /> New Existing Con- Con- glass <br /> Tanks Tanks crete structed <br /> —Sepc >( /oro l tulcse✓ V ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement Ell 0 1:1 <br /> I,the undersigned,assume responsibili for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) PI bees Si a p) MP/MPRS No. <br /> gn (no tams : Business Phone Number <br /> �L'elS o-er r ZzSZZ 7i s- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> II{.Couaty/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) Issuing en ignature tamps) <br /> Determination 07 <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R 07/00) <br />