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Sanitary Permit Application Safety&Buildings Division <br /> ' In accord with Comm 83.21,Wis.Adm. Code 201 W Washington PO Box Ave. <br /> Visconsin WI 302 <br /> See reverse side for instructions for completing this application 5 Box 7 <br /> Personal information you provide may be used for secondary purposes Madison, <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not Y✓ <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper of less than 8-1/2 x 11 inches in size. <br /> CounttState Sanitary Permit Number Li C"if rev Bron to previous plication State Plan I.D.Number <br /> 2y�elrot;e 14t 4 -31052 <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location pC. <br /> r 1+j /¢"S p fJ67l1Vde'l14,S /YT37,N,R!E or <br /> Property Owner's Mailing Address r Block Number <br /> City,State Zip Code Phone Numbera or CSM Number <br /> S ooN er wF I ( 43!r 75;27 V/ 7 <br /> Ill.Type of Building: (check one) ❑City <br /> )2�— 1 or 2 Family Dwelling-No.of Bedrooms: -2 ❑Village <br /> ❑Public/Commercial(describe use):_ J!4own of <br /> ❑ State-Owned 45 <br /> Nearesooa ~ �" <br /> ParoRoad <br /> ,§1111T _Num r(s)oa <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> $) Permit Number 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 ❑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 /> 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 I Tanks <br /> Ti C /060 4 !40d /lid/ GJq S ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(n stamps): MP/MPRS No. Business Phone Number <br /> G ,vA44� 415-,16/„7 Alfr� a --7-76 y/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ,G'�ax-17/ Si/�e SY�72 <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee ncludes Groundwater Date Issued Issuing Signatu ps) <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee) . /�Y� y b <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />