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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 /> `VRsconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned.) 00Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. 00 <br /> County State S itary Permit Number heck if revision to vious application S Ian I.D.Nu ber <br /> #a <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner NameProperty Location �/ <br /> L/ �v�il- 14 <br /> /�/�'� l" 9/4$ 1/4,S.2y TY1,N,R'/f(or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> C'ty,State Zip Code Phone Number Subdivision Name or CSM Number <br /> ��1y� ( <br /> II.Type o uilding: (check one) ❑city <br /> �71 or 2 Family Dwelling-No.of Bedrooms.. r� ElVillage <br /> ❑Public/Commercial(describe use):_ 3 own of <br /> ❑State-Owned LeJ .5 <br /> Nearest Road <br /> Parcel T Numbet <br /> (s Z 0..� O <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) I. ew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <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 9vtound ❑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 /> Ja d 62;!5� a / 99, .Z <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 strutted <br /> Tanks I Tanks <br /> 10, s'� S6 D ❑ ❑ ❑ ❑ <br /> 41 <br /> II.Res risibility 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(n stamps): MP/MPRS No. <br /> Business Phone Number <br /> Plumber's Address(S et,City,State,Zi ode) <br /> 2— <br /> IX.County/Department Use Only Issuin�$ n <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued <br /> t Sire(No stamps) <br /> Approved 1 ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />