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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 /> VlscOnsfn 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 /> (x <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. state owned.) <br /> Coun State Sanitary Pe it u Ceck' is'op to pn:viou�a lication State Plan I.D.Number <br /> krnea Q <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name VV ` Property Location <br /> Sv­ae� t�-oe <br /> yl 1` C 1/4 Lf A,S ZO'1'7b,N.d7(o <br /> Property Owner's mailing Address ` Lot Number <br /> -7 Sb , n � S /' Block Number <br /> City,State / I Zip Code * Phone N7)r Subdivision Name or CSM Number <br /> autSt��r (,�1; S o c7 , Y3-3/30 <br /> II.Type of Building: Vheck one) ❑City <br /> 16 1 or 2 Family Dwelling-No.of Bedrooms: 6P,- ❑Village <br /> ❑Public/Commercial(describe use):_ IXTown of <br /> ❑ State-Owned u `t <br /> Nearest Road <br /> S R IUler <br /> Parcel Tax Number(s1 _� 20-01 00 <br /> rB) <br /> ype of Permit: (Check only one box on line A. Check box on line B if applicable) OO <br /> 1. New 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. 11Addition to <br /> System System Tank Only Existing System <br /> ❑A Sanitary Permit was previously issued Permit Number Date Issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-groundMound ❑Sand Filter 11 Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑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 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 3© 0 00 � a � / 9S 96r 8 <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 (41m �0 — <br /> x OaDCXj 1 ❑ ❑ ❑ <br /> LI X (Coo ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibili for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plu ber s Signa ( stamps): MP/MPRS No. Business Phone Number <br /> Nfts kvr r 2-2-S-1 �s- $�6- <br /> Plumber s Address(street; aCk <br /> City,State,Zip Code) <br /> (> V 71� r <br /> IX.County/Department Use Only t. <br /> 07i;1!: Sanitary Pe Fee(Includes Groundtyater D sued Issuin ent S' n s) <br /> ved ❑Owner Given Initial Adverse Surcharge �� <br /> Determination - <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> BD-6398(R.07/00) <br />