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,J! - 6/) <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> Visconsin 7302 <br /> PerSee reverse side for instructions for completing this application Madison,WI POBox-7302sonal information you provide may be used for secondary purposes <br /> Department of Commerce [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 11 inches in size. <br /> County /erne State xnstary Permit� N ber ❑o2ChV 3 revision to previous application State P0/37 D.Number <br /> I.Application Information-Please Print all Informatibn Location: <br /> Property Owner Name Property Location <br /> G /`'/7/1, -S 'l'j/ke4 1/4 1/4,S 1L 1-'5'A,R-�V(or)Q 00 <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> �3/z G ( psi , s-�s%9so9 <br /> II.Type of Building: (check one) 3 ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ Town of <br /> 11 State-Owned r,pale �// <br /> 4/r <br /> Nearest Ro <br /> Parcel Tax Number(s) <br /> ro <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. 121 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 /> ❑Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground IItHolding 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 Application5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed 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 /> ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(pri Plums Sign ur o ps): MP/MPRS No. Business Phone Number <br /> Fd �r6ext <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 72 /5- -/4 S/ alert L 6L"' <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing a ign o stamps) <br /> D(Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: f <br /> SBD-6398(R.07/00) <br />