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r,4^-/ btoly <br /> = 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 /> Visconsin personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce <br /> [Privacy Law,s. 15.04(I)(m)] (Submit completed forth to county not <br /> state owned. <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 Sanit ermit Ne ❑C ck if revision to previo application State Plan 1.D.Number <br /> �3 6a sem, a <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> 0 1/4 1/4,SZ;lyN,R m <br /> Property Owner's Mailing Address r e *�b;b 19 r./ Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> GJ c%s fer w t syk7z 9-x933 <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> Public/Commercial(describe use): 'Town of <br /> ❑ State-Owned V_� V_V 01 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearott Road Q <br /> A) 1. 13 New System 2. replacement 3. ❑Replacement of 4. El Addition to Parcel Tax Number(s) <br /> System <br /> Tank Only Existing System ©l ,2$ D S/ 7 00 <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> i"on-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> 0 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(Gals./day/sq.ft.) (Min./inch) Elevation <br /> �o v ya 9 ye3.�e 1-3 , -' 9 <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 /> ❑ ❑ ❑ ❑ <br /> lul- <br /> 11 ❑ ❑ ❑ ❑ <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(prin Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ,6O >e <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued - Issuing Age Signa a ps) <br /> proved ❑Owner Given Initial Adverse Surcharge Fee <br /> Spermination lJ) Ir 0}1 �ifJ_®O <br /> Det <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 tJ <br />