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Sanitary Permit Application Safety&Buildings Division <br /> Visconsin <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W Wa P i Box on ve.See reverse side for instructions for completing this application <br /> 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)foX the system,on paper not less than 8-1/2 x I 1 inches m size. <br /> County State Sanit Permit Number ❑ eck if revision to pr vious application State Plan I.D.Number <br /> i'li -7 43 co 4Fs G <br /> I.Application Information-Please Print all Information J Location: <br /> Property Owner Name Property Location <br /> L�ocation <br /> V� Gtr/,rTIQYI ,"'^tel/4(J /4,SST9 ,N,R'` <br /> /i W <br /> Property Owners Mailin Address Lot Number Block Number <br /> tZ3 t ssehl <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> rs1 s v W; I ?-2,600 <br /> II.Type of Building: (check one) ❑City <br /> X 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): 19 Town of I, <br /> ❑ State-Owned r�,e <br /> 111.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Neggrestgoad <br /> A) I. ❑New System 2. )83 Replacement 1 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numbe ) <br /> System Tank Only Existing System I o,3 I.W+O Loo <br /> B) Permit Number Dale 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 /> RequiredProposed Rat/Gal(Gals./day/sq.ft.) (Min./inch)10 1 �� Elevation <br /> q�D ZTSS0 �rT5_ . 7� ga. 7 Z <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 /> f.c X00 W asap' 19 ❑ ❑ ❑ ❑ <br /> v <br /> 1< I 1000 ❑ ❑ ❑ ❑ <br /> II.Responsibility Statement <br /> I,the undersigned,assume responsibitity for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(P* t) P umber s Signat e( tamps): MP/MPRS No. Business Phone Number <br /> <S pev 2-Z 9'22 6- a''hoJo- <br /> Int ber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Perm t ee(Includes Groundwater Date Issued Issuing ge t Si afore mps) <br /> Approved ❑Owner Given Initial Adverse Surchar e F <br /> Determination D �� <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />