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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> ��seonsin information <br /> reverse aide for instructions for completing this application PO Box 7302 <br /> Department or commerce Personal formation 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 complete Laos to the coon co and f the system,on paper not less than 8-1/2 x 1 l inches in size. <br /> County State Sanitary ertnit Number Check if revision to pre 'ow application State Plan I.D.Number <br /> L Application Information-Please Print all Information Location: <br /> Property Owner Name Property Loeation <br /> l <br /> � <br /> f, 1 <br /> Property ars Mailing �� / Z �l/44 S+2 d T Q <br /> JLot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> G W S <br /> II.Type of Building: (check one) �. ElCity <br /> I or 2 Family Dwelling-No.of Bedrooms: i-77 ❑Village / <br /> Public/Commercial(describe use): '— Town 04-r— <br /> ❑ <br /> State-Owned �f /J I <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. 13 New System 1 2. ;P&Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Only Existing System O/oZ a7.zg O /0( <br /> B) Permit Number Date Issue4 <br /> ❑A Sanitary Permit was previousl issued <br /> IV.Type of POWT System:(Check all that apply) <br /> AI.Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Welland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At- de ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dis ersaVTreatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 1 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(GalsJday/sq.It.) (Min./inch) Elevation <br /> -3a a � _ %3L.� 9.5= 4s; <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 /> CS G' JC QVC) S^p r0 ct)4C2jGo� ❑ ❑ ❑ <br /> ;Z fiL <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I the undersigned,assume responsibilitv for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si ( temps)- PRS No. Business Phone Number <br /> �� <br /> Plumber's Address(Strut,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> ❑DisapprovedSanitary Permit Fee(Includes Groundwater Date Issued Issuin eat s ps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) j L� <br /> c' Determination Q(� <br /> IX.Conditions of Approval/Reasons for Disapprov <br /> SBD-6398 R07/00 <br />