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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 /> See reverse side for instructions for completing this application PO Box 7302 <br /> `�sconsin personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce (Submit completed form to county if not <br /> [Privacy Law,s. 15.04(1)(m)] <br /> state owned. <br /> Attach complete plans to the county copy only)for the system,on papSr not less than 8-1/2 x 11 inches in size. <br /> County State snit Perini Nu r ❑ ck if revision to previ us application State Plan I.D.Number <br /> e <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> W1/4 V 1/4 S.2-7T ,N,R14 E o <br /> Property er' Mailing Address Lot Number Block Number <br /> 07:6710 Xi5ffZ %2V_ 6 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 3HYE9 W1_ �4$q� is v <br /> I Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: _3 ❑village <br /> ❑ Public/Commercial(describe use): ow,n�off <br /> ❑ State-Owned /444^10 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Ne X,stRoaA Al 07Sd <br /> A) I. ew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Nu ber(s) gpo <br /> System Tank Onl) Existing System 020 43Z'7 �S <br /> B) Permit Number Dale Issued <br /> ElA Sanitary Permit was previously issued <br /> Type of POWT System: (Check all that apply) <br /> PKINon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑ ressurized 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 Pro used Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 44_4P 643 X048 1- 94 . 0 U - 0 <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 sttucted <br /> Tanks Tanks <br /> _ M ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.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(no m MP/MPRS No. Business Phone Number <br /> c�ftRO ZZ-�851 l�- 5� <br /> umber's Address(Street,City,State,Zip Co e) <br /> Z-77&0 1. 91 <br /> VIII.County/DepartmcnVUse Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin ent Si tute mps) <br /> 1pproved E3 Owner Given Initial Adverse Surcharge Fee) 03 <br /> Determination (8�l <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />