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ON COMPUTER/SCANNED <br /> 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 /> ®�SCOnSin Personal information you provide may be used for second purposes p Madison,WI 53707-7302 <br /> Department of Commerce (Submit completed form to coup if not <br /> [Privacy Law,s. 15.04(1)(m)] (S p �' S <br /> state owned.) <br /> Attach complete plans(to the county copy only)for he system,on paper not less than 8-1/2 x I 1 inches in size.Co un e State Sanitary Permit Number ❑ h k if r ision to previou pplication State Plan I.D.Number /0`,/ <br /> C$6 5 7 <br /> -54056 <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name i Property Location i <br /> \J O X , 3 61 e le r- 1/4 1/4,S 7 T Ya,N,R E(or(o <br /> Property Owner's Mailing Address Lot Number Block Number <br /> /;2 yr3 �7 sf cl,�; 3 <br /> City,State Zip Code Phone Number / Subdivision Name or CSM Number <br /> S 0 <br /> II.Type of Building: (check one) ❑city <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ 9FTown of <br /> ❑State-Owned <br /> Nearest RRRad L <br /> Ai <br /> Parcel Tax <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable)M-41A A,40-1,5-07� <br /> A) 1. PLNew 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 /> ❑Non-pressurized In-ground O-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 /> /SO / so / Sd — <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 strutted <br /> Tanks Tanks <br /> y� <br /> 4 4 .�Qt) ❑ ❑ ❑ ❑ <br /> II.Responsibility Statement <br /> 1,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 /> or <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing e t Signature stamps) <br /> Ck-Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination 27 4G- 6� <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />