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lanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21, Wis.Adm. Code 201 W.Waihington Ave. <br /> *6eonsin <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 53707-7302 <br /> Department of Commerce <br /> [Privacy Law,s. 15.04(I)(m)J (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 8-112 x t I inches in size. <br /> Coun V C-NVState Sanitary P m ❑ �kg re� pteyious application State Plan 1.D.Number <br /> L Application Information-Please Print all Information tLocation: J <br /> Property Owner Name i Property Location <br /> o I $ JJJCLj (o �' i $ 1 <br /> ?roperty Owner's Mailing Address Lot Number 1/4,S�1 T �Bl R1 Number Block Number <br /> SLtnrC_ GPt� ZCJz <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 6„!' C. s-98 3 zJ ( ) <br /> II Type of uilding: (check one) ❑City <br /> Q` 1 or 2 Family Dwelling—No.of Bedrooms: ❑Village <br /> 7 Public/CommercW(describe use): Jill Town of <br /> State-owned <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road . <br /> -\A <br /> A) I. Q New System 2. ❑ Replacement 3. ❑ Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> Svstem Tank Only Existing System 11-1715---0 j — G OD <br /> B) Permn Number Date Issued <br /> 4 Sanitary Permit was previously issued 37 8 9 9 <br /> V.T pe of POWT System: (Check all that apply) <br /> Ji'.�lon-pressurized In-ground ❑ Mound ❑Sand Filter ❑ Constructed Wetland <br /> J Pressurized In-ground ❑ Holding Tank ❑Single Pass ❑ Drip Line 1 <br /> 7 At-grade . T f, ❑AerobiccJ tment Unit E3 Recirculating EI Other: I <br /> U o I t G L.c. `n, t <br /> Dispersal/Treatment Area Information: <br /> Design Flow(gpd) 2.DispersaWca 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.1) (Min./inch) QJ,?ee)'O Elevation t_ <br /> -0 Sro o s y /' a C ysa5 ✓ 00-_l t7t <br /> /I Tank Capacity in Total of Manufacturer Prefab Site Steel Fiber- Plastic <br /> aformation Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks I Tanks <br /> Z IzSo IzYG Cl ❑ ❑ <br /> ❑ Cl ❑ ❑ ❑ <br /> 11 Responsibility Statement <br /> L the undersigned,assume responsibility for installation of the PO WTS shown on the attached plans. <br /> 'umber's Name(print) Plumbers Signature(no s ): MP/MPRS No. Business Phone Number <br /> tamp <br /> 11 <br /> John Solofra #223779 715-376-2278 <br /> 'umbers Address(Street,City,State,Zip e) <br /> PO Box 161; Gordon, WI 54838 <br /> III County/Department Use Only <br /> ��JJ ❑Disapproved Sanitary Permit F (Includes Groundwater Dau Issued Issuing Agent Signature ) <br /> tpproved ❑Owner Given Initial Adverse Surcharge Fee) <br />��YY �- Determination �G 6( <br /> Y.Conditions of Approval/Reasons for Disa royal: <br /> SdQ�t _ 0C <br /> Zo NG�Nry <br />