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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> Vise See reverse side for instructions for completing this application PO Box 7302 <br /> onsin personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce Submit completed form to coup if not <br /> [Privacy Law,s. 15.04(1)(m)) ( P county <br /> state owned. <br /> Attach complete plans to the county copy only)for the systm,on paper not less than 8-1/2 x 11 inches in size. <br /> County State Sani a it er 11Chetif re ' t ovvi us application State Plan I.D.Number <br /> I.Application Information-Please Print all Information Location: <br /> Pro erty Owner Name ) Property Location <br /> b N f 'ed_.5'0 'j1/4 1/4 S 5'-T3f,N R'E(or) <br /> Property Owner's Majling Address Lot Number Block Number <br /> nU tp(/ <br /> � )e ITA <br /> City,State Zip ode phone Number Subdivision Name or CSM Number <br /> Inlo '5 <br /> Il.Type of Building: (check one) ❑city <br /> 1 or 2 Family Dwelling-No.of Bedrooms. ❑Village <br /> ❑ Public/Commercial(describe use): [KTown of <br /> ❑ State-Owned Lp-rd//e e <br /> I1I.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest RoaP y69r / <br /> /� r <br /> A) 1. b!�Plew System 2. ❑ReplacemenEIReplacementof 4. ❑Additionto Parcel Tax Number(s) <br /> S stemnk Only Existing System Id Ajja 0.6— d <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued 130 <br /> IV.Type of POWT System: (Check all that apply) .,..�r� <br /> ❑Non-pressurized In-ground .8&ound ❑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 i .Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> y5e S1So ys�4 /01.8 <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 strutted <br /> Tanks Tanks <br /> ❑ ❑ ❑ ❑ <br /> C 40 00 C) <br /> �( 6oa baa ❑ ❑ ❑ ❑ <br /> I.Res risibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) / Plluumber's Signature o stamps): MP/MPRS No. C� Business Phone Number <br /> ejlA <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> ❑Disapproved I Sanitary Pemyi Fee(Includes Groundwater Date Is ed Issuing A en ign re s) <br /> roved ❑Owner Given Initial Adverse Surcharge FdII� S J`� N A <br /> Determination —JN L ! (J� <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />