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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 /> Visconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce Submit completed form to county[Privacy Law,s. 15.04(1)(m)] ( P tyf not i <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on p4per not less than 8-1/2 x I 1 inches in size. <br /> County e State Sanitary Permit er it Number Che irevision to prev us application State Plan I.D.Number <br /> U <br /> 7 $ <br /> I.Application Information-Please Print all InformatibnLocation: <br /> Property Owner Name Property Location <br /> e - Aj e- /i / 1/4 1/4,S T y0,N,R,J'(or) <br /> PropertyOwner's Mailing Address Lot Number Block Number <br /> 130 X a 3sf 3 e <br /> City,State Zip Code Phone Number Subdivision Name ocC,$)jNxuber <br /> 51� C 0") W F 15W7A ( > z- ')40 e�j 140.t.ir,.1 t6 U, if <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ 12KTown of <br /> ❑ State-Owned <br /> f}C- <br /> Neareq Rofd n / <br /> s.J �c+W Yo rJ�✓ <br /> Parcel Ia Numbe s)r O 5 ocJ <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 /> ANon-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/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 /> -3o ° y3-?- 1 -7 1 ` <br /> r 6 ,6� <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 /> ❑ ❑ ❑ ❑ ❑ <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. Business Phone Number <br /> 17d 4� <br /> Plumbe/r'S Address(Street,City,State,Zip Code) <br /> IX,County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin Agent Signature(No stamps) <br /> proved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination •VlJ j��� m '/LJ <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />