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Sanitary Permit Application Safety&Buildings Division <br /> 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 /> `*5consin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to 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 i P <br /> State S e N r ❑Check if revision to previous a plication State Plan I.D.Numb ��/ l <br /> nl 4 025 J <br /> I.Application Information-Please Pr' t all I formati n U Location: <br /> Property Owner Name Property Locatio <br /> V ! J <br /> u c�^ O c� `� 1/4 1/4,J2 T39 ,N,It E(or <br /> Property Owne09 Mailing Address Lot Number Block Number <br /> 5-/ .9 ..2- ST <br /> City,State Zip Code Phone Number c or CSM Number <br /> II.Type of Building: (check one) ❑arty <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> Town of <br /> PubliPublic/Commercial(describe use):_ <br /> c/Commercial 'l <br /> ❑State-Owned sAAII 4AK Ile_ <br /> Nearest Road <br /> Parcel Tax Number( a o <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) —2�a <br /> A) 1. eUNew 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 /> �ilNon-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 /> 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 /> L c D®rJ Dao 6 l <r/GSe o <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 stain s): MP/MPRS No. Business <br /> Phone Number <br /> (/tom G &X a 117- <br /> Plumber's Address(Street,City,State,Zip Code) .01 <br /> 'd 6 /V .S 'r� e") <br /> IX.County/Department Use Only <br /> ❑Disapproved I Sanitary Permit Fee(Includes Groundwater Date Issued Issuin ent S' o stamps) <br /> 'Approved ❑Owner Given Initial Adverse Surcharge Fee <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R 07/00) <br />