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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 /> Visconsin See reverse side for instructions for completing this application PO Box 7302 <br /> 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 /> Counlb State Sanitary Permit Number ❑C if isi.ntop_reviou pplication State Plan I�5 her <br /> u► vie �'F- 93 ,� 4- ' <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner <br /> arne Property Location <br /> vee to' l I 0 SC. 1/4/)"A,S� W <br /> IT3 ,N,1�4-* <br /> Property Owner's M ing Address Lot Number Block Number <br /> 6 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> i > U) 7 A (7/s 381 V,-7 f S� <br /> II.Type of Building: (check one) ❑city <br /> Iffi' I or 2 Family Dwelling-No.of Bedrooms: r5l- ❑Village <br /> ❑Public/Commercial(describe use):_ VTown of <br /> ❑ State-Owned L®`Pf1 o-1 <br /> Nearest Road <br /> wOGtlG�r uc.f� <br /> Parcel Tax Number(s)O f - 2 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) J <br /> A) 1. Pq New 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 ❑Holding Tank ❑Single Pass ❑Drip Line <br /> X 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 /> 3°� tfo� 7 3a 6-,;)- <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 Tanks <br /> ❑ ❑ ❑ ❑ <br /> VIII-Responsibility Statement <br /> I,the undersigned,assume responsibilitS for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plu bees Signature no ps): MP/MPRS No. Business Phone Number <br /> ,els tee i � � �s� �- /S 6=tea <br /> Plumber's Address(Street,City,State,Zip Code) <br /> �s cit,, rl;L <br /> IX.County/Department Use Only <br /> / ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Iss ed Issui A t Signat tamps) <br /> l3 Approved ❑Owner Given Initial Adverse 1 Surcharge Fee) <br /> Determination /Z Qt), -03 <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R 07/00) <br />