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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 /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. state owned.) <br /> County State Sanity Permit Number ❑Check if revision to previous application State Plan I.D.Number <br /> 4457o1 C # 083 6 <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name �+� Property Location <br /> 1/4 1/4,S;2V T96,N,R'-! orW <br /> Properly Owners ailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number <br /> r Subdivision Name or CSM Number <br /> �'v�st sa,J �i.rl 5573 -5 ( > V /y 6 <br /> II.Type of Building: (check one) ❑City <br /> PlAi or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ gown of <br /> ❑State-Owned T,,�C-�$a!J <br /> Nearest Road <br /> Parcel T Numb r(sQb �0 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. Jellmw 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 /> pl�gon-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/1 reatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Ar=eral4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Rate(Gals./day/sq,ft.) (Min./inch) Elevation <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks �+ <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 stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> �/ ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Age Signature(Nos ) <br /> I! Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination 09 " <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> IRwEv (blur Graf( Edjwre�rfa [ P12/blt iusbr 'r <br /> SBD-6398(R 07/00) <br />