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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> `Wisconsin personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [privacy Law,s. 1 be us d for (Submit completed form to county if 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 I1 inches in size. <br /> County State Sanitary Permit Numer ❑Check if revision to previous application State Plan I.D.Number <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> 1 <br /> To� e/,4�� �/� S&1/4 3- 1/4, lid-05Fo <br /> Property Owner's Mailing Address Lot Number Block Number <br /> Y� y awa/ /4v� �, / /,1-s <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> tpRWl MAA 0 y diz 6J?5'--s3_26 <br /> II.Type of Building: (check one) ❑C'Ty <br /> V� 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): ^^ 'Town of <br /> ❑ State-Owned lrW/S S <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> 4 <br /> A) I. .New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s)y_Z3 p-63- <br /> S stem Tank Only Existing System d__3o <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> Ion-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) ry� Elevation <br /> 7 97, 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 crete structed <br /> Tanks Tanks <br /> A, POO,) loop No!'wc;;—C_ <br /> VII.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 /> wA a/euf;rWo/.0, 1 G✓a. :o,-7 7 G <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ,B 0.t- L�_., ) 4✓.7- .SV k 7,2 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuirif ent S' tamps) <br /> proved ❑Owner Given Initial Adverse Surcharge Fee l / , <br /> Determination CYC/ <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> 'BD-6398 R07/00 <br />