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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 /> Asconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of commerce [Privacy Law,s. 15.04(l)(m)] (Submit completed form to county if not <br /> state owned.) C�Q <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 State Sanitary Permit Number ❑YhAk if revision to previ84 application State Plan I.D.Number <br /> n1c 446 7351 rl <br /> -'r— <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> 2 t�— A., /e- IL/ 1/4 1/4,S S Tag,N,Rf E or) <br /> Property Owner's Mailing Address hat- I tber Block Number <br /> Gs�gra- Ael �/ G.G • G <br /> City,State Zip Code Phone Number bdivision Name or CSM Number <br /> 4141 1 svk ( )3 <br /> II.Type of Building: (check one) ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ ;Rl-Town of <br /> ❑State-Owned <br /> Nearest Road -LL <br /> Parcel T tuber OC^ _ Ot7 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) 7 <br /> A) 1. 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 /> VNon-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(GalsJday/sq.R.) (Min./inch) 1Elevation <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 /> �p00 / � � ❑ ❑ ❑ ❑ <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(p int) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> 7z4� <br /> Plumber's Address/Street City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issum Agent Signature(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) Q u <br /> Determination -V ' 1 VPOLI <br /> X. onditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />