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Sanitary Permit Application Safety&Buildings <br /> `�r In accord with Comm 83.2 1,Wis,Adm. Code 201 W.Washingt ve. <br /> seonsin See reverse side for instructions for completing this application PO BoWWjW <br /> Personal information you provide may be used for secondary purposes Madison,WI 53707-�� <br /> Department of Commerce <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to count?~ <br /> state <br /> Attach complete plans to the county copy only)for the syetem,on paper no ss than 8-1/2 x 11 inches in size. <br /> County State Sanitary Perm, um ®C4ecf visiop,to previous app ation State Plan 1.D.Number <br /> I.A ication Information-Please Print all I for tion a Location: <br /> Property Owner Name Property Location <br /> 1/4 1/4,S IS <br /> Q T <br /> Property OwArs Mailing Address Lot Number Block Numbe <br /> P.O. " 12- <br /> city,state Zip ,47 30 Phone ISlutgbe5,65 S js Subdivision�„ a o�SM Number <br /> �^^�' lt�/ (0 Zap // ,_[(l/�(Jy, �lli2 / <br /> II.Type of B it ing: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑ Public/Commercial(describe use): own of ' 1 <br /> ❑ State-Owned t-ft✓vl/ <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) ares[ adna <br /> . <br /> A) L New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel_Tax Nu er(s <br /> System Tank Only Existin System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> .,I,,,,V��..-"Type of POWT System: (Check all that apply) <br /> futon-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) Ele ation li <br /> 45V <br /> VI.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 /> G 1C to 1 NORW _uo ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.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(no stamps): MP/MPRS No. r Business Phone Number <br /> Gl�Att?O w <br /> umber's Address(Street,City State,Zip Co e) <br /> 2-'7760 82tj 3S W156M lAlI- S4$93 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit F (Includes Groundwater Date Issued Issuing Agent Signa re s ps) <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee) ^, 1 <br /> Determination uV —�✓ X <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />