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r <br /> SU <br /> Sanitary Permit Application Safety&Buildings Di <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington t e <br /> �- See reverse side for instructions for completing this application PO Box 0 <br /> Nvseonsin personal information you provide may be used for secondary purposes Madison,WI 53707-7 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county <br /> state o <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Permit Number ❑C k if rpNisi n to previous plication State Plan 1.D.Number <br /> S <br /> I.Apillication Information-Please Print all In or aiion Location: <br /> Property Owner Name Property Location r <br /> {i:1�'�' 1/4 1/4,�3T�,N J-45; o W <br /> Property Owner's Mailing Address Lot Number wac- <br /> 50-7 J;JVJC145014 5t% 2 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> '5402l <br /> iS >�9B-27ss <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑ Public/Commercial(describe use): XTown of nC�o� <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 �^ j <br /> A) L XNew System 2. ❑Replacement 3. ❑ Replacement of 1 4. ❑Addition to Parcel Tax Num er(s, /��, <br /> System Tank OnlyExistingSystem 2 3 oat 0D <br /> B) 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(Gals./day/sq.ft.) (Min./inch) Elevation <br /> -7 <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 structed <br /> Tanks Tanks <br /> L /AGS -� /DIXJ / NoRwo ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII. Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's dame(print) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> umber's Address(Street,City State,Zip Code) <br /> 2.7760 -jS 1�1�SSr�K loll- S4$G3 <br /> VIII.Co nty/Department Use Only <br /> ❑Disapproved Sanitary Perm ee(Includes Groundwater Date Iss d Issuing ent Si amr s rips) <br /> Fppro <br /> ved ❑Owner Given Initial Adverse Surcharge Fee M <br /> Determination t C CJ o <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R071100 <br />