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Sanitary Permit Application Safe �ildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> `�sconsin See reverse side for instructions for completing this application PO Box 7302 <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 com Tete lans to the county copy only)for the stem,on 2a2er not Icss than 8-1/2 x I 1 inches in size. state owned. <br /> Count State Sanitary Permit Number ❑Chec �f evsioq to preyipus ation State Plan I.D.Number <br /> I.A cation Information-Please Print all Information Location: <br /> Property Owner Name <br /> �jt,l_/ Property Location // <br /> VTI]V j MARK 1.1 NSl'.14 EI p 1/4 1/4,S240,N,F14E or <br /> Property Owner's Mailing Address <br /> 11 RID A-/- C_ Lot Number gaff <br /> City,State Zip Code 3 L' <br /> P�I PhonjlJtyttber�gs-?s�� Subdivision Name or CSM Number <br /> II.Type of Building: �p W I1 3 _ h rO <br /> YP g: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: Z ❑Village <br /> ❑ Public/Commercial(describe use): 1fown of <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> NB) <br /> ❑New System 2. $[Replacement 3. ❑Replacement of 4. ❑Addition to Pazcel TaxNew System 2. AlfReplacement 3. Replacement of 4. ❑Addition to Tax Numbes)S stem Tank Onl Existin S stem .10 Permit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System: (Check all that apply) <br /> on-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.Dis ersal/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) <br /> 300 Elevation <br /> 429 43z Rs.o 9S.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 structed <br /> �Tanks Tanks o� <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I the undersi ned assume res onsibili for installation of the POWTS shown on the attached lans. <br /> Plumber's Name(print) Plumber's Signature( o s ps): MP/MPRS No. <br /> Business Phone Number <br /> J <br /> Plumbers Address(Street,City,State,Zip C e) J(5 ✓ <br /> ?-MO llnt _16- 0C6t rR W1 • <br /> VIII.County/Department tse Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Age Signa re(N ps) <br /> ;roved ❑Owner Given Initial Adverse Surcharge Fee <br /> Determination 191) <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />