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C-I� 1 z 'aa <br /> Sanitary Permit Application Safety&Buildings Dn <br /> SIn accord with Comm 83.21,Wis.Adm. Code 201 W.Washingto ve. <br /> 'Wisconsin See reverse side for instructions for completing this application PO B2 <br /> Department of Commerce Personal information you provide may be used for secondary purposes Madison,WI 53712 <br /> (Privacy Law,s. I5.04(l)(m)] (Submit completed form to court t <br /> state <br /> Attach complete plan to the county copy only)for thestem.on DaDer no ss than 8-1/2 x l I inches in size. <br /> County State Sanitary Permit © ec rf isiop to arevious apriNcation State Plan 1.D.Number <br /> I.APPliC2tiOn Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> Ma 1/4 1/4.S G T#O,N,R/y E or _ <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 6 T6 Dam I/ <br /> City,State Zip Coe Phone Number Subdivision Name or CSM Number <br /> ej-6ravq et /Nr 6-12)77 ( 6I <br /> II.Type of Building: (check one) Cl City <br /> '® t or 2 Family Dwelling-No.of Bedrooms:— Z ❑Village <br /> ❑ Public/Commercial(describe use): 19 Town of <br /> ❑ State-Owned 5�ff <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road Lk �r <br /> A) 1. ❑New System 2. �Reply ementjW5�� <br /> 3. ❑ Replacement of 4. ❑Addition to Parcel Tax Nu ber(s) <br /> System Tank Only Existing System OZ$ /00 02 AN> <br /> B) I Permit Number Date Issued <br /> ❑A Sanity Permit was previouslyssued <br /> IV.Type of POWT System: (Check all that apply) <br /> ONon-pressurized In-ground 11 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 Inform tion: <br /> I.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 75.PeTcolationRate 6.System Elevation 7. inal Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) Elevation <br /> 42dj Z/ Z • 7 46.3 q83 <br /> VI.Tank Capacity in Total of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tank <br /> JCL19 `� /UaN ❑ ❑ ❑ ❑ A <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) i Plum ers Signature(no stamps): :vI P/MPRs No. Business Phone Number <br /> 2.2 S$Ste/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 277(o o H :?S^ �/£$Sl"cR WI q <br /> VIII. County/Department Use Only <br /> ❑Disapproved Sanitary Permit ee((ncludes Groundwater Date[s ued I Issuing Ag n igna <br /> Approved ❑Owner Given Initial Ad verse Surcharge F <br /> Determination �• v L OZ.V <br /> IY.Cond' " s of Approval/Reasons for Disapproval: / <br /> WAG <br /> SBD-6398 R071()0 , <br />