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Sanitary Permit Application Safety&Buildings D <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washingto e. <br /> See reverse side for instructions for completing this application PO Bo <br /> N iseonsin personal information you provide may be used for seconds Madison,WI 5370 2 <br /> Department of Commerce Y P Y secondary purposes (Submit completed[Privacy Law,s. 15.04(1)(m)] ( form to coun [ <br /> state o <br /> Attach complete plans to the county copy only)forthe system,on paper not less than 8-1/2 x I 1 inches in size. <br /> County State Sanita i ❑ k if isiJalloQrevio application State Plan I.D.Number <br /> a <br /> I.ApOication Information-Please Print all Information Location: <br /> Property Owner Name Property Location I <br /> IAN151/4,S1740 <br /> T N )N o W <br /> Property Owner's Mailing Address Lot Number Block Numbe <br /> 1(oS 60VAI AV Q. I V 11 P.ZlS <br /> Cirf,&W <br /> tate Zip Code• Phone Number Subdivision Name or CSM Nu er <br /> ns(l . s'o2s 4- 226 3 g At*,1�5 <br /> II Type of Building: (check one) ❑City <br /> I or 2 Family Dwelling-No.of Bedrooms:_moi' 13 Village <br /> Public/Commercial(describe use): Town of I'A1�1V <br /> ❑ State-Owned �(, <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road ' <br /> A) I. — ew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel T Nymbe ) D' DO <br /> S stem Tank Only Existing System y <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV Type of POWT System: (Check all that apply) <br /> on-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 /> I.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Propo ed Rate(GalsJday/sq.R.) (Min./inch) Elevation <br /> 3z • 7 --� 9Z-- �s <br /> VI.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 /> /000 <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.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 /> A✓ - ?2585/ S - 07 <br /> umbers Address(Street,City State,Zip Co e) <br /> 2-77(0 3S (nJ�PST�K WI• S4$g3 <br /> VIII.County/Department Use Only <br /> ❑Disapproved [Surcharge <br /> anitary Permit Fe (Includes Groundwater Date Issue - Issuing Age Sign r trips) <br /> Approved ❑Owner Given Initial Adverse Fee) f <br /> Determination ' 63 <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br /> / <br />