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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 93.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> PO Box 7302 <br /> '� iSConsin Personal <br /> reverse side for instructions for completing this application Madison,Wl 53707-7302 <br /> Department or commerce l information you provide may be used for secondary purposes (Submit completed form to county if not <br /> [Privacy Law,s.15.04(l)(m)) 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 /> �m„ty State Sanitary Permit er Check if revisjon m previo application State Plan I.D.Number C� <br /> 7�1 <br /> I.App lication Information-Please Print all Information Location: <br /> Property Owner Name Property Location / <br /> t 1/4 1/4 S? T O,N K�o W <br /> O GCJ Lot Number <br /> Property Owner's Mailing Address <br /> ity.State 92 Zip Code Phone Number S> Natne or CSM Number <br /> L S" <br /> II. ype of Building: (check one) ❑City <br /> ❑Village <br /> 1 or 2 Family Dwelling-No.of Bedrooms: Kfown of <br /> ❑ Public/Commercial(describe use): A <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box online A. Check box online B if applicable) NeaN <br /> /'A) 1. PjewSystem 2. ❑Replacement 3. ❑Replacementof 4. ❑Additionto P S stem Tank Onl Existin S stemB) Permit Number aimed <br /> ❑A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System:(Check all that apply) ❑Sand Filter ❑Constructed Wetland <br /> 1�Ton-pressurized In-ground ❑Mound <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dia ersal/Treatment Area Information: 7. <br /> L Design Flow(gpd) <br /> Z.Dispersal Area 3.Dispersal Acca 4.Soil Application 5.Percolation Rate 6.System Elevation Elevation rade <br /> 77 <br /> Req�uit/e`d'� Proposed Rate(GalsJday/sq.ft.) (Min./inch) <br /> J ( J b/Y __ <br /> VI.Tank Capacity in Total #of Manufacturer Prab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Coon- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> ❑ ❑ ❑ ❑ <br /> Vorave co <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I the undersi ed assume res ibili for installation of the POWTS shown on the attached plans. <br /> i <br /> Business Phone Number <br /> mber's Name rint) / <br /> Plumbers Signature stamps): MP/MPRS No. <br /> Plumber's Address(Street,City,State,Zip Code) —7 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent Si o <br /> �Agproved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination I C� <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />