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Sanitary Permit Application Safety&Buildings Division <br /> v 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 /> Vrisconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce Submit completed form to <br /> [Privacy Law,s. 15.04(1)(m)] ( P 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 11 inches in size. <br /> County State Sani4uy Permit Number ❑Checkif revision to previ s application State Plan I.D.Number f7 pQ <br /> &fAe /D <br /> I.Application Information-Please Pri t all Information Location: <br /> Prope Owner Name Property L9caop G o 9 <br /> E C rclr/ a ra25nw 1/4 1/4,S/,rr,r, ,RCSE(or <br /> Property Own Mailing Address Lot Number Block Number <br /> �9 <br /> City,State �p Code Phone Number Subdivision Name or CSM Number <br /> /00 n <br /> II.Type of B ing: (check one) ❑City <br /> 19 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ JU Town of <br /> ❑State-Owned Z47 <br /> Nearest Road <br /> Parcel Tax Number(s)O <br /> III.Type of Permit: (Check only one box on line A. Check box on lineB if applicable) <br /> A) I. ®New 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 WMound ❑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 /> VSa Yso 5/So /. /Do 16 'r /o z,1 <br /> VII.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 I Tanks <br /> s k /ocn ❑ <br /> / 4�•'cSr r <br /> t— <br /> ❑ ❑ ❑ ❑ ❑ <br /> l� Ca.cr e�e <br /> VII .Resplonsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> [Plumbeels <br /> r' Name(print) Plumbers Signature o 77 ps): MP/MPRS No. Business Phone Number <br /> �Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fe (Includes Groundwater Date I ued Issuing Age t Sign ps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) ® �\ Z_ O <br /> Determination r D <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> • <br /> SBD-6398(R.07/00) � _ <br />