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v64o_w <br /> Sanitary Permit Application Safety&Buildings Division <br /> Sington Ave. <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.WasPO Box 302 <br /> ` ,scons%nSee reverse side for instructions for completing this application Madison,WI 53707-7302 <br /> Department of Commerce Personal information you provide may be used for secondary purposes (Submit completed form to county if not <br /> [Privacy Law,s. 15.04(1)(m)] <br /> state owned. <br /> Attach com tete plans to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> County State S P 't umbe C eck ifryvisjn4 to �us application State Plan I.D.Numbe (fl <br /> I.Application Information-Please Print a1 In ormation Location: Q) <br /> Property Owner Name Property Location <br /> Tim Hoffman &L S <br /> 1/4 1/4,527 T41 IV,R1% W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 21488 Ravenna Tr 33 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Welch MN 55089 -- Minnewaukon Assessors Plat <br /> II.Type of Building: (check one) ❑City <br /> ad 1 or 2 Family Dwelling-No.of Bedrooms: 2 ❑village <br /> ❑ Public/Commercial(describe use): IX Town of E prt Swiss <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 /> Lakes Dr <br /> A) 1. L21 New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System I Tank Only Existing System 032-9230-04 300 <br /> B) Permit Number Date Issued <br /> ❑A 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-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.ft.) (Min./inch) Elevation <br /> 300 250 265 1.2 na 96.75 99.70 <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 /> septic 750 -- 750 1 Wieser Concrete ❑ ❑ ❑ ❑ <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) JaPbe�s Si nam stamps): MP/MPRS No. Business Phone Number <br /> Donald Daniels MP 330/221593 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO Box 316 Siren WI 54872 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundkyater Date Issued Issuing g t Si re tamps) <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee)eq( <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-10705—P (N.01/01) <br /> SBD-6398 R07/00 <br />