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Sanitary Permil Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> isconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <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 t the county copy only)for the system,on pap of less than 8-1/2 x 11 inches in size. <br /> Co State git ber ❑Chec 'f reyasi n to prev' application State Plan I.D.Number <br /> I.Application Information-Pleas rint all Information (� Location: <br /> Property Ownnner Name Property Location c <br /> /t U i �-'� 1/4 1/4,S� yD,N,R/ or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> e713 ?a Y&1.z,w, <br /> City,State r <br /> Code Phone Number c•�wSM Number <br /> I�I.,/.Type of Building: (check one) ❑City <br /> h+.I or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ —_ Ptown of nn <br /> ❑State-Owned TACk5 Q <br /> Nearest RoY I t <br /> /CLi'--e <br /> Parcel Tax Number(s)cw 41.2Z p <br /> 6� <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. F Wew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) 11 Permit Number Date Issued <br /> A Sanitary Permit was previously issued <br /> IY.Type of POWT System: (Check all that apply) <br /> Non-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.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 crete structed <br /> f Tanks I 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 N (pri Plumber's Signature(no tamps): MP/MPRS No. Business Phone Number <br /> nt <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Age gn (No s) <br /> roved ❑Owner Given Initial Adverse Surcharge Fee) -I <br /> Determination ?-, C <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />