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Co <br /> lanitary Permit Application Safety&Buildin Division <br /> Visconsin <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Waihington Ave. <br /> 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 33707-7302 <br /> Department or Commerce (Privacy Law,s. 15 04(1)(m)] (Submit completed form to county if not <br /> state owned.) (l . <br /> Attach complete plans to the county copy only)for the system,on paper not less than 8-I/2 x 11 inches in size. KJ <br /> Coun State Sanitary Permit Number ❑ revi roc to previous kation State Plan 1.D.Number <br /> UtAr 4 3 x53 U <br /> I.Avolication Information-Please Print all Information Location: <br /> Property Owner Name ( Property Location <br /> �"ec'V -r 1/4 SE 1/4,S ;Z- T�' ,N,I)VE or W <br /> Pmpeny Owners Mailing Address Lot Number Block Number <br /> W <br /> 5-13 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> re 0 888 1 ( 3S ) roo <br /> II Type 6f Building: (check one) ❑City <br /> )il— 1 or 2 Family Dwelling—No.of Bedrooms: 3 ❑Village <br /> O Public/Commercial(describe use): ItTown of '/ <br /> O State-owned RJ S l� <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road C <br /> Sw <br /> A) L )!�New System 2. ❑ Replacement 1 3. ❑Replacement of 1 4. ❑Addition toParcel Tax Number(s)s) <br /> Svstem Tank Only Existin S stem O - 3/0 1 -o yoo <br /> B) <br /> 13 Permit Number Date Issued <br /> A Sanitary Permit was previously issued <br /> r <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 /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V Dia ersanreatment Area Information: <br /> 1.Design Flow(gpd) 2.DispersalArea 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gal ./day/sq.R) (Min./inch) Elevation <br /> 3 �? 3 77 9/. 70 <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 I Tanks <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII Responsibility Statement <br /> I,the undersigned,assume responsibility for' lati WTS shown on the attached plans. <br /> ?lumber s Name(print) Plum gn (n ): MP/MPRS No. Business Phone Number <br /> John Solofra #223779 715-635= 3706 <br /> Plumbers Address(Street,City,State,Zip Code) <br /> /Vr336 Toc.. '/tkl ltd. ak)A-cr [,)-�. S" Y90 <br /> VIII County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin Agent Signature(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) �� <br /> .Determination / <br /> DL Conditions of Approval/Reasons for Disapproval: <br />