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Sanitary Permit Application fety&Buildings Division <br /> 201 W.Washington Ave. <br /> in accord with Comm 8321,Wis.Adm Code PO BOX 7302 <br /> Viswnsin <br /> See reverse side for insbtrctions for completing this applicatioj:"37 Madiso4 53707-7302 (�Personal information you provide may be used for secondary purleted form to county if not YDepartment of Commerce (Privacy Law,s.15.04(lxm)) state owned.)Attach complete plans(to the county copy�Y)for the system,on paper lessize.County3 O� 11 <br /> tate Plmmber <br /> trP o_ Location: <br /> I.Application Information-Please Print all Information 'Jf&/ <br /> Properly Owner Name ��/1/4/vw 1/4,S </ T-Tr,.R�rE(or� <br /> Cee Lot Number Block Number <br /> property Ownen Mailing Address <br /> ' 3(n <br /> �s 4 l Subdivision Namk or CSM Number <br /> y,State <br /> Zip Code t, Phone Number <br /> f v � o tIm SS6 "! ( its/ ) G 90— 9z rr ❑city <br /> IL Type of Building: (check one) ❑Village <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms' in Town of <br /> ❑PublidCommucial(describe use):_ <br /> iUSx- <br /> ❑State-Owned <br /> NesGstRoad <br /> umber(s)in 2 J/aZ <br /> III Type of Permit: (Check only one box on line A. Check box on lime B if applicable) 5 6. ❑Addidom to <br /> A) 1. New 2. ❑Replacement 3. Tank Only Rep Dement of 4. Existing System <br /> Systema System Dau Iss <br /> B) PennitNumber <br /> ❑A Sanitary Permit was prevlousiy issued <br /> IV.Type of POWT System:(Check all that apply) ❑Sand Filter ❑Constructed Wedand <br /> Rf Non-pressurized la-groLine <br /> und ❑Mound <br /> ❑Pressurized Inipound ❑Holding Tank ❑Single Pass ❑Drip <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other. <br /> V.DispernVFrestment Area Information: 7.Final <br /> 1.Design Flow(gpd) 2.Disposal Area 3.Dispersal Area 4.Soil icatimn 5.Percolation Rate 6.System tacwatan Elevation <br /> Required Proposed Rate(GalsJday/sq.ft) (Minlnch) <br /> VII.Tauk Capacity m Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- gl <br /> New Existing trete strutted <br /> Tanks Tanks <br /> /cc l Lv:ese-r <br /> (coo Ce.1 C Wk <br /> VIII.Responsibility Statement <br /> 1,the undersigned,assume responsibility for installation of POWTS shown on the attached plans. <br /> MPAGMS No. <br /> Business Phone Number <br /> um ane ) � -� l�✓��,5� <�,J� �.SJ�.` <br /> Plumber's Address(Sired,City,State,Zip Code) n <br /> 44, S reef. <br /> IX.County/Department Use Only <br /> 11 Disapproved Sanitary Permit F (Includes Cnoundwater Date Issued I Signature stamps) <br /> Approved ❑Owner Givrxi Initial Adverse Surdrarge F«) a U Vcc <br /> I L`� s/ <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: 1 <br /> N� 0 <br />