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V/G . <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> sevnsinSee reverse side for instructions for completing this application PO Box 7302 <br /> Department oT Commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> [Privacy Law,s.15.04(l)(m)) (Submit completed form to county if not <br /> Attach co fete lens to the coup copy only)for s stem on a e not less than 8-1/2 x l 1 inches in size. state owned.) f� <br /> County Shte Sanitary P i ❑ if re gion to revio application Sfato Plan L er� _Z> <br /> s UIL A Hcation Information-Please Print all In ormaHon Location: <br /> Property r Name <br /> / Property Location // <br /> Property a Mailing Address 1/4 1/4 S T N IC or <br /> 3 `� / Lot Number Block Number <br /> City,area / Zi Code N &• L•t <br /> P Phone Number Subdivision Name or CSM Number <br /> II.Type of Building: (check one) ❑City <br /> t or 2 Family Dwelling-No,of Bedrooms: ;-2- 0 village e <br /> ❑ PublicXommercial(describe use): �1own of / <br /> ❑ State-Owned ��/t�! <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest R°°Z 35� <br /> A) I. ❑New System 2. replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax umbers) p -1 <br /> System <br /> Tank OnlyExistin S stem 006 Q O e) <br /> B) Date tsaued <br /> 11A Sanitary Permit was previgyaly issued Permit Number <br /> IV.Type of POWT System:(Check all that apply) <br /> ❑Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground 94iolding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dis ersal/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 /> Q Re9utred Proposed Rate(GalsJdsy/sq.R) (MinJinch) 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 trete strutted <br /> / Tanks Tanks <br /> E(d/�tJ Aid o�001� �'p¢LcJ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> the undersi d assume res ibili for installation of the POWTS shown on the attached plans. <br /> Plumbers Name(pri Plumbers Signature(no ): MP/MPRS No. Business Phone Number <br /> >�e kSlalih G� �Z7�� kyr-72 <br /> Plumbers address(stmt,city,state,zip code) A0 C=� <br /> a S/eyS.�G G✓ SY8 72 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date I ued Issuing t Si ) <br /> proved ❑=Given Initial Adverse Surcharge F 00. <br /> Determination rt/® <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07M <br />