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Sanitary Permit Application Safety&Buildings Div <br /> Visconsin <br /> In accord with Comm 83.21,Wis.Adm. Code � 201 W.Washingto See reverse side for instructions for completing thitc3t PO Box <br /> Personal information you provide may be used for sec r Madison,WI 53707 <br /> Department of Commerce Submit completed form to coup o <br /> [Privacy Law,s. 15.04(1)(m)] ( P ry <br /> state o <br /> Attach complete plans to the county copy only)for stem,on paper not LkCss than 8-1/2 x I I inches in size. <br /> County State it P t tuber ❑ e if rev' ' n to revious app'cation State Plan I.D.Number <br /> i.AppTication Information'-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> : kx COOK 1/4 1/4.SZT `^^ N, QI <br /> Property Owners Mailing Address Lot Number <br /> 5G µ1CIWLS Sr- Z OL- 4 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> .S'T'. Aub AIAI- 5511 (oSi )73S-3554- ✓„ (o F- 1 <br /> II.Type of Budding: (check one) ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): Town of c <br /> ❑ State-Owned .SW 135 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest RoadJDM!M� <br /> Aj <br /> A) L ❑New System 2. `.12 Replacement 3. ❑ Replacement of 4. ❑Addition to Parcel Tax Numb! s) <br /> System Tank OnlyExistingSystem d Z 52ZL _s"00 <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <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.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.R.) (Min./inch) Elevation <br /> *52) �¢� a �9 17 0_ - 91. 9 qs <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 Tanks <br /> SE G IOOn --- 11000 <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> 7 <br /> �� a.✓ A - ?2585/ S- - /S7 <br /> umbers Address(Street,City State,Zip Code) <br /> 2-71K 35' W156 TEK 111. S4-$g3 <br /> VIII.County/Department Use Only <br /> ❑DisapprovedSanitary Permit Fee(Includesrotfttv�water Date ed - f� Issuing a Signa re o mps) <br /> A ved ❑Owner Given Initial Adverse Surcharge Fee) �(,7��J\ nGb// <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />