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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 PO Box 7302 <br /> IV;sconsn 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 11 inches in size. <br /> CountyState Sani Permit Number ❑C c if rev' ion to previous ap lication State Plan I.D.Number <br /> y�� e 4�j3 eg96 <br /> I.Application Information-Please Print all Information k Location: <br /> Property Owner Name / Property Location / <br /> 'e N /)�l C C�/r U' L( 1/4 1/4,S L TJ S'N,R E(or) <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name order <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ Dkbwn of//'' <br /> ❑ State-Owned /—y 04 �Q`o Q e <br /> N[3LrTrfFn1 <br /> Parcel TaaxmNumber(!) O <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. Wew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> Type of POWT System: (Check all that apply) <br /> on-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 /> Required Proposed Rate(Galslday/sq.ft.) (Min./inch) Elevation <br /> 1 <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 /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> � <br /> Plupmbees/IName int) Plumber's Signature(n ps): MP/MPRS No. / Business Phone Number <br /> l lo <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> 42 <br /> ❑Disapproved Sanitary Permit Fee(Inc udes Groundwater Date Issued gnature ps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) 0 <br /> Determination �y <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> 1 <br /> SBD-6398(R.07/00) <br />