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e <br /> Sanitary Permit Application Safety&Buildings Division <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 /> ��seonsin 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 P be Check if revision previous ap Jicati State Plan I.D.Number <br /> I.Aplification Information-Please Print all In ormation Location: <br /> Property Owner Name Property Location Ll <br /> AW 1/4 1/4,Sl/4T ,N, or W <br /> Property Owneees Mailing Address Lot Numbeerrf Block Number <br /> D IfN ` <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> rnl 5,,� 1 Z 59 >4-N- Evw)wx Ano 7' ✓ <br /> II.Type of Building: (check one) ❑city <br /> 0 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> Public/Commercial(describe use): own of <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road e , <br /> A) 1. *;WNew System 2. ❑ Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s)07 O <br /> System Tank OnlyExistin S stem <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 ❑ 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 /> 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) 1.1 D Elgva)J9it O <br /> 300 i� (oo , s ._-_! W. h/ ` *. <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> t <br /> /AaD �AaD / �/or1�✓ o ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumbers (print) Plumber's Signature(no stamps): MP/MPRS No. r Business Phone Number <br /> �Ir <br /> l0lumber's Address(Street,City State,Zip Co e) <br /> 2.7760 3S W150M J1- <"13 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee ludes Groundwater Date I sue Issui g gent s ps) <br /> JVA.pproved ❑Owner Given Initial Adverse Surcharge Fee) / D <br /> Determination V <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />