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Sanitary Permit Application Safe-t7&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> VhsconSln See reverse side for instructions for completing this application PO Box 7302 X <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 s stem,on paper not ess than 8-1/2 x 11 inches in size. state owned.) <br /> Count', State Sanitary P it Numb ❑Ch revisipp in previous app'cation State Plan I.D.Number <br /> I.Application Information-Please Print a 1 Information <br /> Property Owner Name Location: <br /> Location <br /> e r1-4 Property <br /> c E m /6 <br /> Property Owne Mailing Address 1/4 1/4,S T yo,N,R E(or W <br /> 5- --'2 p / 7 _ Lot Number Block Number <br /> City,State p Code `� -- <br /> Phone Number Subdivision Name oher <br /> ,5-A 1*../ "W'V_ �-s-moo y <br /> g ( ):7;-,7 ,& 7 yZ <br /> D t <br /> II.Type of buildin check one) <br /> 0- 1 or 2 Family Dwelling-No.of Bedrooms: � ❑city <br /> El <br /> ❑Public/Commercial(describe use):_ lfown ofe <br /> ❑State-Owned <br /> 6.4, tet-.�C/ <br /> NearestRQQgd -291C)72 <br /> Pa�12 ax Numbe S) <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) 6 <br /> EEO] <br /> ew 2. ❑Replacement 3. ❑Replacement of 4. <br /> System System Tank Only 5' 6. ❑Addition to <br /> Permit Number Existing System <br /> A Sanitary Permit was previously issued Date Issued <br /> IV.Type of POWT System:(Check all that apply) <br /> Psion-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank <br /> ❑At-grade g ❑Single Pass ❑Drip Line <br /> ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V. 1114,4111 elrs:l I lit 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 Gal;./day/sq. <br /> � O ( ft.) (Min./inch) <br /> y� 7 <br /> y� q Z ; s� Elevation 9 <br /> VII.Tank Capacity in Total #of Manufacturer <br /> Information Gallons Prefab Site Steel Fiber- Plastic <br /> Gallons Tanks Con- Con- <br /> New Existing crete structed glass <br /> Tanks Tanks <br /> ❑ ❑ ❑ ❑ �. <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. <br /> / Business Phone Number <br /> cr Id JC re�ffi s �n G(/«oe oF� 7 L— `1� ?� 3 <br /> Plumber's Address(Street City,State,Zip Code) <br /> _� - w Y- SS— <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Pe ee(Includes Groundwater Date Issued <br /> "pProved 11Owner Given Initial Adverse Surcharge F / Issuing ent Si o s ps) <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />