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Sanitary Permit Application Safety&Buildings Division <br /> �,�► In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> `risconsin <br /> Department of commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> Attach complete plans(to the county copy only)for the system,on papgr not less than 8-1/2 x 11 inches in size. state owned.) <br /> A <br /> County State��Sa�iQ Permit Number ❑ eck if vision to previ us application State Plan 1.D.Number <br /> 4rN� `1'"-509 8�3 Q)C <br /> I.Application Information-Please Print all Information Location: (� <br /> Property thvner Name <br /> Property Location U <br /> O 02 '+M 1/4 1/4,S27T YEN,R E o W <br /> Property er's Mailing Address Lot Number Block Number <br /> City,State / jZipode Phone Number wlsion Name or CSM Number <br /> e � � Yf� ( sal >3/9 .2:7 V G S <br /> II.Type of Building: (check one) ❑ ;ty <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: 02 ❑Village <br /> ❑Public/Commercial(describe use):_ jil-^town of <br /> ❑ State-Owned TA,—k 5d <br /> NearesA Road�j� <br /> P/,.+1 r <br /> Parcel Tax N er(s)otG <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) e <br /> A) 1. ew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Dale Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> AIon-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 Rats 6.System Elevation T Final Grade <br /> Required Proposed Rate(GalsJday/sq.ft.) (Min./inch) Elevation <br /> 3�o y� y32 e '7 — 9s 97./ <br /> VII.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 /> QAa S f}GJ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.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 stamps): MP/MPRS No. Business Phone Number <br /> 2 276 ZZ P <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only / <br /> —ff Disapproved Sanitary Permit Fee(Includes Groundwateq Issuing A gnature stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination v � % <br /> X.Conditions of Approval/Reasons for Disapproval: ✓uA' <br /> 'I <br /> BURN 9 44 <br /> 7-r2p/VlN�U/V7-� <br /> SBD-6398(R.07/00) <br />