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9 30 Z8 541f <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 PO Box 7302 <br /> `�sconsin 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 /> Countyn State,Sanitary P r itt Number ❑Ceck if vision tq preNous application State Plan I.D.Number <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location c� rr�� <br /> 'p—� SC 1/4541 1/4,S ( T..?A,R�E(o) <br /> Property Owne Mailing Address .� Lot Number Block Number <br /> City,StateZip Code Phone Number Subdivision Name or CSM Number <br /> &r"41tJ 5L At . `5-4/9 e ( ) ems" <br /> 11.Type of Building: eck one) ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ P4ewn of <br /> r <br /> ❑ State-Owned 44� �j 4->f/ f r✓ e-011� <br /> Nearest Road �. /- <br /> Parcel Tax N mbe(s <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) pay <br /> A) I. ❑New 2. placement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <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 ;6[ <br /> - and ❑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 Rats(Gals./day/sq.ft.) (Min./inch) Elevation <br /> y�--eD ys® ys o f ��', � o a <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 <br /> S� Odv --- /0.041 ❑ ❑ 11 El <br /> ❑ ❑ ❑ ❑ <br /> II.Respoitsibility 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 stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> .A-1X S/ S / 4---j <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issr�,4mhi, <br /> Signature o ps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) a <br /> Determination ` 00 2 /d <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />