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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 VisconsinMadison,WI 53707-7302 <br /> Personal information you provide may be used for secondary purposes <br /> Department of commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> Sb <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the ystem,on paper nots than 8-1/2 x I 1 inches in size. <br /> County State Sanitary ermit Number ❑Ch k' revis' to revious applic ion State Plan I.D.Number 4 <br /> C4 <br /> del A) e 43'�oSq -7 �.1 <br /> I.Application Information-Please Print all Information Location: <br /> ProperlyOwner ame Property Location <br /> t J � <br /> / C/ <br /> C, 4 w Z e- w/ 5 1/4 1/4,S T YO,N,R E(or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 3;2/ 7 LOri-eL.J� <br /> City,State Zip Code Phone Number Subdirision-Name or CSM Number <br /> II.Type of Building: (check one) ❑city 03K(� JY o r-es <br /> �I or 2 Family Dwelling-No.of Bedrooms. <br /> ❑village <br /> ❑Public/Commercial(describe use):_ own of <br /> ❑State-Owned Ak ( �� <br /> Nearest Road <br /> Parcel Tax Njn,1r(s) .Zf O �a <br /> III.Type of ermit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. w 2. ❑Replacement 3. ElReplacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> �P on-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(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 3o d 5 9,7, 5 <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete structed <br /> Tanks Tanks <br /> ❑ ❑ ❑ ❑ <br /> .5 -e. G DCS .-- Qf7 S�i9-crJ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(pnn Plumber's Signature o stamps): MP/MPRS No. Business Phone Number <br /> e�uYs��► <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Aa,x S-/ .,j <br /> IX./County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin a ps) <br /> Approved 1 ❑Owner Given Initial Adverse Surcharge Fee) tam. <br /> .M <br /> Determination �l1li <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> BU l <br /> -eb <br /> N���N <br /> G TY <br /> SBD-6398(R.07/00) <br />