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Iou <br /> 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 /> Visconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 n` <br /> Department of commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not XJ <br /> state owned.) 6` <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 /> Co u y State Sanitary Permit a ber 11Check if cion to,p u pylic 'on Slate Plan 1.;.umbe. <br /> I.A14 <br /> pplication Information-Please Print all Info ation VJ Location: <br /> Property Owner Name Property Location <br /> le001� ,(�o� � e 1/4 1/4,S3YT,?fN,R/Cor)V <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 3 91 x335 Al G, L-. 3 <br /> City,State Zip Code Phone Number 'Subdivision Name or CSM Number <br /> l <br /> 5'y6o4 ( 7/S )yfl3 �oy5' <br /> II.Type ofBuilding: (check one) ❑Ciy <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ Town of <br /> / r <br /> ❑State-Owned 44000.1 ��L) e-v- <br /> Nearest Road <br /> 4TX'C'» <br /> Parcel Tax Numbe S3 a 5— ejC <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. 1 LNew 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 �&olding Tank ❑Single Pass ❑Drip Line <br /> 13 At-grade bb 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 /> 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 I Tanks <br /> o ,v ��L 66G � ❑ ❑ ❑ ❑ <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 /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit F (In <br /> Appcludes Groundwater Date 71sed Issuing Agentigna roved ❑Owner Given Initial Adverse Surcharge Fee)3 �Determination U <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R 07/00) <br />