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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 /> NOseonsin 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 /> state owned. <br /> Attach <br /> Cori lana to the county copy only)for the system on not less than 8-1/2 x l 1 inches in size. <br /> COun S Sani Permit Number ❑Check if ' ion to previous a lication State Plan 1.D.Number <br /> rLfAlical Information-Please Print all Inf rmationLocation: <br /> Owner Name Property Location <br /> roperty rs Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> � 11(4/' S X30 5 9 a �/ ��. <br /> II.Type of ullding: (check one) p city I or 2 Family Dwelling 61, <br /> -No.of Bedrooms: E3 Village <br /> ❑ Public/Commercial(describe use): Wown of <br /> ❑ State-Owned gO^-` <br /> III.Type of Permit. (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. ❑New System 2. �(Rep�lacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numbers) <br /> S ste Tank Only Existing System cp O S Q <br /> B) Permit Number Date]sued <br /> ❑A Sanitary Permit was previouslyissued <br /> IV.Type of POWT System:(Check all that apply) <br /> La-Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Welland <br /> Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other; <br /> V.Dispersal/Treat ent Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rale 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(GalsJday/sq.H.) (Min./inch) Elevation <br /> O O ya d 9,2,,2 <br /> , <br /> VI.Tank Capacity in Total #of anufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> S i ` 7Sa 1So ❑ ❑ ❑ ❑ <br /> Srni S�rJ 56v ❑ ❑ ❑ ❑ <br /> II.Responsibility Statement <br /> ffs ,,bii ed assume res 'bili for installation of the POWTS shown on the attached plans. <br /> print) Plumber's Signature(no stamps): MP/MPRS No. Q, Business Phone Number <br /> s Street,City,State,Zip ode) �� / �en S- <br /> /Depsrtment Use Only <br /> ❑Disapproved Sanitary Permit Fee ncludes GrouMwater Date[asued Issuing Agent Si o stamps) <br /> ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />