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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 /> See reverse side for instructions for completing this application <br /> COpsin Personal information you provide may be used for secondary purposes Madison,WI153707-7302 <br /> 5Box 7302 <br /> Department of Commerce [privacy Law,s. 15.04(1)(m)1 (Submit completed form to county if not <br /> state owned. <br /> Attach com Tete plans to the county copy only)for the system,on papq not less than 8-1/2 x I 1 inches in size. <br /> Count State Sanitary Permit Nu b ❑C k ifrevision t/p pre io s application State Plan 1.D.Number n�2'2. <br /> -tT' OCJ.7, � V �/ <br /> I.Arplication Information-Please Print 0 Information Location. <br /> Property Owner Name Property Location <br /> Lu1/99*k W6£a 1/4 1/4 S T ,N E jorl <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 25034 LAIeV14;t,/ -_ 1( <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> SIRIEW wi. A19u <br /> II.Type of Building: (check one) o city <br /> • 1 or 2 Family Dwelling-No.of Bedrooms: Z ❑Village <br /> Public/Commercial(describe use): Town 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 `A <br /> A) 1. ❑New System 2. Xeplacement 3. ❑Replacement of 4. ❑Addition to Pa e], 1A <br /> A) sr <br /> System <br /> Tank Only Existing System <br /> B) Permit Number O I 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 AMolding 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 /> NA Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> VI.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 /> moo � Z000 1 Sk-R-r✓ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <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 /> 225 SI 1715- &6 467 <br /> - <br /> P mber's Address(Street,City,State,Zip C de) <br /> Z77(o0Awv36 Wf 1 . <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing A on stamps) <br /> Ap vedTDetermination <br /> ❑Owner Given Initial Adverse Surcharge Fee) l� /a , OT <br /> ®J (JV U <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />