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Sanitary Permit 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 /> iseonsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce Submit completed form to county[Privacy Law,s. 15.04(1)(m)1 ( P if not <br /> state owned. <br /> Attach com tete plans to the county copy only)for the system,on paper not less than 8-1/2 x I 1 inches in size. Ll <br /> County State Sanit Pe it Num er ❑Check if revisiop to parev a:�kation State Plan L D.Number <br /> I.Application Information-Please Print all Aformation Location: <br /> Property Owner Name �/ Property Location <br /> �j� /J,/ AA,, / <br /> Property Owner's Mailing Address //'� Lot Number Block Number <br /> L G_ �p <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> A4yi 1-k N. <br /> II.Type of Building: (check one) ❑City <br /> T 1 or 2 Family Dwelling-No.of Bedrooms: Village <br /> ❑ Public/Commercial(describe use): Town of L, / <br /> ❑ State-Owned 1 ,�1.VlfJ <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. XNew System 2. ❑Replacement 3. ❑ Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> S stem Tank Onl Existing System b 3A- -bl- (Otn <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> 3gNon-pressurized In-ground ❑ Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> Cl 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 i <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min✓inch) Elevation <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 /> ° ° <br /> I <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 /> lf�A,+2/> .✓ - .2125157 S - ­07 <br /> Plumbers Address(Street,City State,Zip Co e) <br /> 2-77/0 3S W£i3sr Wl• 54893 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent Signature(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) U� I �'\ � <br /> Determination u U V <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> t <br /> SBD-6398 R07/00 <br />