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C. . <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> PO Box 7302 <br /> Visconsin See reverse side for instructions for completing this application Madison,W153707-7302 <br /> Department of commerce Personal information you provide may be used for secondary purposes (Submit completed form to county if not <br /> [Privacy Law,s. 15.04(1)(m)] state owned. <br /> Attach complete plans to the county copy only)for the system,on paper not less than 8-1/2 x I 1 inches in size. <br /> Cou State Sanitary,P�e '[ u b ❑Check' revision to previouk application State Plan L D.Number (� <br /> I.Application Information-Please Print all Information Location: <br /> PropertyOwne Name Property Location / <br /> ( � Uc ��5 1/4 1/4,S T ,N,Iior W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> Ci State /' Zip Code Phone Number S bdititsion Name,orCSIN Num.,be�r. �� <br /> Ci%�cISJ`2Y�1 /I�f1J 5�0 lv5 S7/09� �ee�. X471;f f/^clal, (D !� <br /> II.Type of Building: (check one) ❑City <br /> ,)&- 1 or 2 Family Dwelling-No.of Bedrooms: ❑Town of <br /> ❑ Public/Commercial(describe use): r- �L�S O <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest 13,oad <br /> get �� <br /> A) L fi!rti w System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parc 1 Tax Numbs) 3 O 7 p <br /> System Tank Onl Existin S stem 12 ? <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> oNon-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 RateT67;�S-ys—t;Elevation 7.Final Grade <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 /> S � f ` 60v doo � orGu.�Sc;v ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume res onsibili for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print)) Plumber's Signature(no s ps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fe Includes Groundwater Date Issued Issuin A nt S' stamps) <br /> roved ❑Owner Given Initial Adverse Surcharge Fee) / <br /> Determination ( / <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />