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ISConsi - -u <br /> 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 15 Box 7302 <br /> Wisconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce bt <br /> [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 Sanit milt Number ❑ eck if revision to pr ious application State Plan I.D.Number <br /> 7`r Cb. <br /> I.Application Information-Please Print all Information Z Location: <br /> Property Owner Name Property Location <br /> S f0h Zp $%444 1✓Wi/4 S 3 T W,N,RjE or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> (a `I7 7 Old i9 <br /> City,Stele Zip Code Phone Number Name or CSM Number <br /> W-eFr.- WT S'tr sq 3 yes- - 7"r I �ov C crr <br /> II.Type of Building: (check one) a ❑village <br /> 19 1 or 2 Family Dwelling-No.of Bedrooms: lig Town of <br /> ❑ Public/Commercial(describe use): <br /> ❑ State-Owned Yi'1 t°Y n p 17 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road , If <br /> A) 1. 18LNew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s)3 ^ O <br /> System Tank OnlyExistingSystem <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> [&Non-pressurized In-ground ❑Mound D 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 /> L 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 /> 3O6 LO_g '4,30L 1 , 7 9J}S�- t 6 <br /> VI.Tank Capaci 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 /> ❑ ❑ ❑ ❑ ❑ <br /> I/ ❑ ❑ ❑ ❑ ❑ <br /> Id��Cf <br /> VII.Responsibility Statement <br /> I,the undersigned,assume res on ibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(n s ): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip de) <br /> J 7 7 6&4 35' w,66s h r- W2:7- s2/e2 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Ag t ign s ps) <br /> ❑Approved IJ Owner Given Initial Adverse Surcharge Fee)1W l �/l G <br /> Determination Zvyt( /J <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> �f 1 c--b n 0t <br /> ke <br /> SBD-6398 R07/00 <br />