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-Nanitary 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 /> ` sootisin 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 forth to county if not <br /> state owned. <br /> Attach complete plans to the county copy only)for the p2tcm,on paper not less than 8-1/2 x I 1 inches in size. <br /> County ��t State Sanitary Permit N m Ch rcvj{ion to previo application State Plan 1. Number <br /> P �F <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> ,M �l A 1 <br /> / t0N'�- f'►E�W �.• V�14�u l G I O /V " 1/4 W 1/4,SZ T YO,N,Rf �E <br /> Property Own s Mailing Address Lot Number Block Number <br /> NO d <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> S DONe3 S4 80 ( ']rte ) 633- tTiT4 <br /> II Type of Building: (check one) ❑City <br /> til- I ort Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> Public/Commercial6 Town ofCommercial(describe use): c CQ <br /> 7 State-owned J <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road* A <br /> A) 1. New System 2. ❑ Replacement 3. ❑Replacement of 4. ❑Addition to Parcel T Number(s -C A O <br /> System Tank Onlv Existing S stem 3-17—a 3 D-Z�, <br /> B) Permit Number Date Issued <br /> 13A Sanitary Permit was previously issued <br /> V.Type of PO WT System: (Check all that apply) <br /> pd!Non-pressurized In-ground ❑ Mound ❑Sand Filter ❑ Constructed Wetland <br /> 7 Pressurized In-ground ❑ Holding Tank ❑Single Pass ❑ Drip Line <br /> 7 At-grade ❑ Aerobic Treatment Unit ❑Recirculating ❑ Other: <br /> V Dispersal/Treatment Area Information: <br /> I.Design Flow(gpd) 2.DispersaWea 3.Dispersal Area 4.Soil Application5.Percolation Rate 6.System Elevation i <br /> 7.Final Grade <br /> Required Proposed Rate(Ga ./day/sq.ft.) (Min./inch) Elevation <br /> ,q SO 3S- 3 ) ' 771. 2- 90.81 - F2,6� 7y-97 <br /> _R Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> nformation Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks I Tanks <br /> _Sc is /000 loon I ("3 r- S a ❑ ❑ C3 13 <br /> ❑ ❑ ❑ ❑ ❑ <br /> /II Responsibility Statement <br /> I,the undersigned,assume res onsibili f in lati n of tOTOAITS shown on the attached plans. <br /> lumber's Name(�rint) P nods to 'tnu"jgs)i MP/MPRS No. Business Phone Number <br /> re,ca f1t <br /> .daUi7 (P I IP d — <br /> lumbees Address(Sued City,State, ip Cfa <br /> 'III County/Department Use Only <br /> ❑Disapproved Sanitary Permit (Includes Groundwater Date Issued Issuing Agqt Sign ps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee Q „l / <br /> Determination l7� <br /> X.Conditions of Approval/Reasons for Disapproval: <br />