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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 /> `�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 /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x I 1 inches in size. <br /> County State San$���t Number ❑ eck if revision to revio application State Plan I.D.Number <br /> Ufn� a of 3F <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name <br /> �--� c_ Property Location <br /> !c V 1/4 1/4,S Z3T.3�,Rt (or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> /yam <br /> --l -City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Soh• (f,&tie � ( > C m / Q Z 6(a <br /> II.Type of Building: (check one) ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ RTown of <br /> ❑State-Owned <br /> r0.i <br /> crest RoaaRct <br /> /`Ole- <br /> Parcel <br /> ` .�C <br /> Tax Numbers)d 3 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. New 2. <br /> El 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 A 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 T.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> y� Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> `. 1lso I 41s0 <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 /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu O'sName(p/nqt}'/ Plumb e Signa a(no s): MP/MPRSS No. <br /> �Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Acdef <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Pemdt Fee(Includes Groundwater Date Issued Issuing gent Signature(No stamps) <br /> Kpproved ❑Owner Given Initial Adverse Surcharge Fee) g F <br /> Determination ��• U/ <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> L <br /> JUN3 0p <br /> SURNE�COv <br /> SBD-6398(R.07/00) <br />