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Sanitary Permit Application Safety&Buildings Division <br /> Visconsin <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W Washington Ave. <br /> Box 7302 <br /> 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)for the system,on paper not less than 8-1/2 x I 1 inches in size. <br /> CountyState Sanitaryermit Number ❑C if revision to revious pplication State Plan I.D.Number <br /> v/ y� 445676 9344-93(49 <br /> I.Application Information-Please Print all Information Location: J,1 <br /> Property Owner Name Property Location l <br /> l Ch lW01 L y N All n r 1/4 1/4,S 2JT3b',N,R-,-F(or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 2 G . rv. Sh6 <br /> City,State 11 Zip Code Phone Number Subdivision Name or C9h44mber <br /> W 5-1;0 'w ( ) N.f�ort �,g,tiJt/�e ,i <br /> II.Type of Buildi g: (check one) ❑City <br /> 0--1 or 2 Family Dwelling-No.of Bedrooms: _ ❑Village <br /> ❑Public/Commercial(describe use):_ B=rown of Q <br /> ❑ State-Owned 410e)el/l iaC <br /> Nearest Road <br /> .v, 3 r <br /> Parcel Tax©be ) x <br /> p <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. eplacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) PemtitNumber )��� te ssued <br /> Sanitary Permit was previously issued I (�. �10��J Da — <br /> IV.Type af POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground Omound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.DispersalfIrreatment 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 Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> S�Sa5^0 <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 /> Se J�/C /mod ��oo ❑ ❑ ❑ ❑ <br /> y/rl �Sl� 7 J'rb ❑ ❑ ❑ ❑ <br /> II.Rksponsibility Statement <br /> 1,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 /> Q <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin Signa o stamps) <br /> Nr/Approved 1 ❑Owner Given Initial Adverse Surcharge Fee),/.) ..' .y <br /> Determination �� ( d p 3 <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />