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Sanitary Permit Application Safety&Buildings Division <br /> V1SCOnSin <br /> In accord with Com 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this.application PO Box 7302 <br /> mPersonal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce Submitcom completed if not <br /> [Privacy Law,s. 15.04(1)(m)] ( p �' <br /> state owned. <br /> Attach complete plans to the county copy only)for th system,on paper pot less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Permit N r D Ch k if;eviyon to reviou pplication State Plan I.D.NumberlVt -� <br /> I.AP01cation Information-Please Print all Information Location: <br /> Property Owner Name Property Location ��22 J <br /> 1/4 1/4 s25T40,N, !* or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 5325 QWQA 2- 33 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> CQ 5TAL 4- 5542$ 3 )63&- 404 0VWLAY%Jb ADD -1b V•V- <br /> II.Type of Building: (check one) ❑City <br /> 0 1 or 2 Family Dwelling-No.of Bedrooms: � ❑Village <br /> ❑ Public/Commercial(describe use): Town of��`�"� <br /> ❑ State-Owned -TACM <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> ,r�Ft <br /> Si� <br /> CIQ- <br /> A) 1. New System 2. ❑Replacement 3. ❑Replacement of 4. 13Addition to Parcel Tax Number(s) <br /> System TankOnl ExistingSystem - O -oZL� <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System: (Check all that apply) <br /> �1Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> �j 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 /> 475b (043 648 96.0 .3 <br /> VI.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 <br /> "� 1Ot>o ❑ ❑ ❑ ❑ <br /> �Ooo <br /> �01206SC0 <br /> ❑ ❑ ❑ ❑ ❑ <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 sta s): MP/MPRS No. Business Phone Number <br /> tcAPAP A0PP-1#4 - 225857 IS, 43M" 4157 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 2,'7-7&0 N 35 W4851W, W►. 54s43 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit (Includes Groundwater Date Issued Issuing Agent Sign re(N ps) <br /> ,�p, —roved ❑Owner Given Initial Adverse Surcharge Fee /}{) <br /> 6�^P Determination Jr. " /N3'02 <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />