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Sanitary Permit Application Safety&Buildings Di <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washingto . <br /> See reverse side for instructions for completing this application PO Bo <br /> `�sconsin Personal information you provide may be used for secondary purposes Madison,WI 5370 2 <br /> Department of Commerce [Privacy Law,s. 15.04(I)(m)] (Submit completed form to county <br /> state o <br /> Attach complete plans to the county copy only)for the system,on a er of less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Pe i mb r heck i9kyision to e. iou application State Plan I.D.Number /� <br /> WOW <br /> I.AppTication Information-Please Print all I rmatton Location: <br /> Property Owner pName <br /> yy ] Property Location <br /> mi Wl/1� 5-V6asno A, /1/4,S�� [ l` ,N,R o W <br /> Property Owner's Mailing Address Lot Number Block Numbe <br /> SICK) q1 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> d 40 A61065 <br /> II.Type of Bu ding: (check one) '7 ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ` ❑Village <br /> ❑ Public/Commercial(describe use): own of �, �� <br /> ❑ State-Owned "x t 6 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road 7 <br /> A) 1. XNew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to I P-1 Tar M,mhrr/cl <br /> System I Tank Onl Existing System -r7 - - - - Q- 01 AOX <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> jy.Type of POWT System: (Check all that apply) <br /> Non pressurized In-ground ❑Mound ❑ Sand Filter ❑Constructed Wetland <br /> ❑ ressurized 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 /> 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 /> t L )6 �Sb ❑ ❑ ❑ <br /> L Sao Sao ❑ ❑ ❑ <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 /> umber's Address(Street,City State,Zip Code) <br /> 2.T760 3s Wigs 6J1. _54$93 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit (Includes Groundwater Dat Is ue Issuing ge Si atu (No tamps) <br /> roved ❑Owner Given Initial Adverse Surcharge F / f <br /> Determination CA—' V <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />