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Sanitary Permit Application Safety&Buildings D t n <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Was O Bo <br /> PO Box <br /> `�SConSin See reverse side for instructions for completing this application Madison,WI 5370 <br /> Personal information you provide may be used for secondary purposes (Submit completed form to county' o <br /> Department of commerce [privacy Law,s. 15.04(1)(m)] <br /> state o <br /> 21111. <br /> Attach complete plans to the countyco only)for th s stem,on paper not less than 8-1/2 x I 1 inches in size. <br /> County Stale Sanitary Permit N e C c]r.�f rev' to previous a lication State Plan I.D.Nu <br /> I.ApAication Information-Please Print all In oma 'on Z Location: <br /> Property Owner Name Property Location <br /> �N 1/4 N 1/4 S N, o <br /> L <br /> Property Owners Mailing Address <br /> Lot Number Block Number <br /> 2a?93 T Rn. a qF Rohs <br /> City,State Zip Code 7PLhoneNumber Subdivision Name or CSM Number <br /> � ) <br /> I._Type of B ilding: (check one) ❑ <br /> CityJ <br /> T�t'1 illllage <br /> 1 or 2 Family Dwelling-No.of Bedrooms:_ Town of <br /> ❑ Public/Commercial(describe use): <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road , <br /> A) 1. ❑New System 2. _3WCteplacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Num er(s) 03 �nO <br /> System Tank Only ExistingSystem <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> IV 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 El Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> I.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soii Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 0 425 4�2 -"� •� q3 -qJ-1- qS.o -%.z <br /> ;V1,Tank Cap6inTotal #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> rmation Gallons Tanks Con- Con- glass <br /> New crete structed <br /> TanksI� �T/bX ❑ ❑e WO ❑ ❑ <br /> VII.Itesponsibility Statement <br /> I,the undersigned,assume res on ibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no stamps): MP/MPRS No. BF;�P-hone Number <br /> v� - 12SSS/ - /S7 <br /> umber's Address(Street,City State,Zip Co e) <br /> 2-37603S W�esr W1. 54$93 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Iss d issuing t Si r I ps) <br /> 16 <br /> rrovedTo Given Initial Adverse Surcharge Fee) 0 <br /> p Determination r <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />