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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 /> Visconsin See reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for second purposes Madison,WI 53707-7302 c, ' <br /> Department of Commerce (P . y ( )( )1 p Submit completed county'rf � <br /> nvac Law,s. 15.04 1 m ( p eted forth to coon not J <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. state owned.) <br /> be <br /> Count n1e- �tISta anitary Permit Number ❑ ck ifrwi 'onto prev us application State Plan I.D.Number�u/' Z <br /> L Application Information-Please Print all In ormation Location: <br /> Property Owner Name Property location G <br /> LF 1/4 01/4,S�7 T3 ,N,R/E(or)ro <br /> Property Owners Mailing Address Lot Number Block Number <br /> oy D <br /> City,State Zip Code Phone Number Sttpdirisiem#ame or CSM Number <br /> S/✓�e,IJ W� SYS' 7 �- ( ) t�%� 3 S 5� <br /> II.Type of Building: (check one) ❑city <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ )ff9 own of <br /> ❑State-Owned A 45-1 L"P�C:)Ili <br /> Nearest Road <br /> GJooa <br />_ Parcel Tax Number(s)� <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) 11 Permit Number Date Issued <br /> A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> t Aon-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.R.) (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 crete structed <br /> Tanks Tanks <br /> -S7�0 7S-d ❑ ❑ ❑ ❑ <br /> Soo -/ ❑ ❑ ❑ ❑ <br /> II.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(n stamps):' MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) Jr <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing rgna stamps) <br /> WA/pproved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination 0 ` <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R 07/00) <br />