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Sanitary Permit Application Safety& Washgs 'v ion <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washin ve. <br /> See reverse side for instructions for completing this application 15 02 <br /> `Wisconsin Personal information.you provide may be used for secondary purposes Madison,WI$3 02 <br /> Department of Commerce [privacy Law,s. 15.04(1)(m)] (Submit completed form to cou not <br /> state d. <br /> Attach complete plans to the county copy only)for the system,on paper not less than 8-1/2 x l I inches in size. <br /> County State Sanitary P Number ❑Check if re isiont revious application State Plan 1.D.Number <br /> � <br /> c/ _S�1/ <br /> I.ApAcation Information-Please Print all Information Location: <br /> Property Owner Name Property Location � ''[[ <br /> I/4 I/4,SL-q/ ,N R/GB or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 3 C'S/71111.7 f l9 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> l-t1i 54893 <br /> II.Type of Building: (check one) El City <br /> I or 2 Family Dwelling-No.of Bedrooms: 3 ❑Towi wof <br /> n <br /> ❑ Public/Commercial(describe use): TD N� <br /> ❑ State-Owned �T <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> trJ:" <br /> A) 1. `�New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax N mber(_s) <br /> S stem Tank OnlyExistingSystem a�� <br /> B) Permit Number Date Issued <br /> ❑A Sanita Permit was previously issued <br /> SiIV.Type of POWT System: (Check all that apply) <br /> on-pressurized In-ground ❑Mound C3 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(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 46 <br /> o 94-3 9-7, 0 <br /> VI.Tank Capacity in Total ii of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons I Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> pfrc <br /> tboo — loco 1 5k.At✓ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume res onsibili for installation of the POWTS shown on the attached fans. <br /> Plumber's Name(print) Plumbers Signature(no stamps): MP/MPP�RSS No. Business Phone Number t <br /> umbers Address(Street,City State,Zip Co e) <br /> 2L77Ioo 3S W156 W1. 94$93 <br /> VIII.County/Department Use Only <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Date slued Is Agent Signature(No stamps) <br /> LApprovedoOwner Given Initial Adverse Surcharge Fee) /�termination v ^� <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07100 <br />