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Sanitary Permit Application Safety&Buildings Division <br /> 201 W.Washington Ave. <br /> III accord with Comm 83.21,Wis.Adm. Code PO Box 7302 (� <br /> See reverse side for instructions for completing this application Madison,WI 53707-7302 x� <br /> :ons�n Personal information you provide may be used for secondary purposes (Submit completed form to county if not <br /> ent of Commerce [Privacy Law,s. 15.04(1)(m)] state owned.) <br /> Attach complete plans(to the county copy only)for system,on paper not less than 8-1/2 x 11 inches in size. U) <br /> Counto State Sanita7rri yp ❑C if revision to previous a lication State Plan 1.D.Number <br /> I.Application Information-Please Print all Information Location: <br /> rope <br /> Properly Owner Name f Prty Location C,// ,r a /i4 /r✓ ' r 1/4SC 1/4,S.? Tj'XN,R7"E(or '1 <br /> Property Owner's Mailing Address Lot Number Block Number <br /> r'23 ;?o / e-- UJ <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 6 r,4J5`e4r . O F 1 ( )h� `rte <br /> II.Type of Build g: (check one) city <br /> or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> Rr-Town of <br /> ❑Public/Commercial(describe use):_ r <br /> ❑State-Owned <br /> Nearest Road <br /> ��` Com/ <br /> Parcel Tax Nimiey <br /> 'o <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ew 2. ❑Replacement 3. ❑Replacement 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 /> ❑Non-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.DispersaVrreatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Ana 3.Dispersal Area 4.Soil Application 5.Percolation Rate T6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <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 strutted <br /> Tanks Tanks <br /> ❑ ❑ ❑ ❑ <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(print) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> 7e I '- 7yy-���� <br /> Plumber's Address(Street,City,State,Zip Code) Ile <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit W(Includes Groundwater Date Issued Issuing ge Sig s) <br /> 107 <br /> Approved ❑Owner Given Initial Adverse Surcharge Fe �40 —/ � Q <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />