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cnayl,�o <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 /> `4sconsin 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 tom Tete plans to the county copy only)for the system,on paper not less than 8-1/2 x I 1 inches in size. <br /> County ` 5 State Sanitary Pe N b heck' revision to previous ap 'cation State Plan I.D.Number <br /> /v�- 7t <br /> '614 P <br /> I.Application Information-Please Print a In ormatiou Location: <br /> Property wnerName / Property Location <br /> 5E t/4 Sr-i/a TQr T S'l(/N,R45�(or <br /> Property Owner' ailing Address Lot Number Bleckbtumber <br /> 5' G/� C -*C� X /? <br /> City,State Zip Code [Ph-one Number Subdivision Name or E6ht�iatt>t>Gj/tr� <br /> e�54/% 6o S 8 866-8y83 <br /> II.Type of Building: (check one) ❑Cit' <br /> P, 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): 0-Town of <br /> ❑ State-Owned ;r'51 c S 0/ / <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road GP ce Cie 4A <br /> / <br /> A) 1. XNew System 1 2. 11Replacement 1 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Only Existing System 1 0/.2 966-0 <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ^on-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) Elevation <br /> VI.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 Tanks <br /> St fit DOd !4d J arw�sc,o <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 ps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing A nt S' afore o s ) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) �✓� O <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />