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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 /> `�seons�n 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 (Submit completed form to coup if not <br /> ' [Privacy Law,s.15.04(I)(m)] ( P county <br /> state owned. <br /> Attach complate plans to the county copy only)for the system,on paper not less than 8-1/2 x l 1 inches in size. <br /> CW N State Sanitary P:Mlg Check i vision ip/Previous plication State Plan I.D.Number <br /> L Application Information-Please Print all In ormation �( Location: j IF <br /> Property Owner Name Property Ile- <br /> Property Location kaj <br /> �`" D e nJd/r e 1/4 1/4 T% N,R E oc w O <br /> Property Owner's Mailing Address Lot Number Block Number <br /> ec ;z <br /> City,State JF Zip Code Phone Number Subdivision Name or CSM N'urqber <br /> SJre A) �.►� 5 87 �- _20,70 Br" /e (f, A <br /> II.Type of Building: (check one) ❑City <br /> J*—I or 2 Family Dwelling-No.of Bedrooms: 3 13 Village <br /> ❑ Public/Commercial(describe use): <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest RopA� <br /> A) L [Q&cw System 1 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel T•axxCSjNumber(s) r'1 <br /> System Tank Only Existing System C9/,2 - 91,2 DOVD <br /> B) Permit Number Date Issued <br /> 13A SanitaryPermit was previouslyissued <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 e ❑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.) (MinJinch) Elevation <br /> yso 6v3 o&/- / _7 3, s ?713 <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Galion Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> St is Oo0 /DOd o(tc(lescp 13 ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume MEMibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature o stamp): MP/MPRS No. Business Phone Number <br /> aAde- l�wfs/o%, CrJa 1 4;2 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> sxv <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Data I ued is ent Si o ) <br /> #WPI-oved ❑Owner Given Initial Adverse Surcharge Fa / Q o I <br /> Determination W r v t� <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6396 R07100 <br /> i <br /> NOV <br /> WMNETT COUNTY <br /> ZONING <br />