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Sanitary Permit Application Safety&BuilAiViLivision <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Was ve. <br /> `�irlrio/fSin See reverse side for instructions for completing this application B1x 7302 <br /> Department of commerce Personal information you provide may be used for secondary purposes Madison, 7-7302 <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form t ty if not <br /> caned. <br /> Attach tom lete tans to the coon co only)for the s stem,on a er not less than 8-1/2 x 11 inches in size. <br /> County t S tPermit Numb ❑Che if revision to previous application State Plan 1.D.Number NO <br /> I.Applicatio <br /> n Information-Please Print all Information Location: <br /> Propewner Name Property Location <br /> �C 1/4 1/4,S T ,/��N,AE or <br /> Property Ownds Mailing Address <br /> Lot Number Block Number <br /> 96 144rlgr <br /> Ci ,State Zip Code Phone Number Subdivision Name or CSM Number <br /> fFlNCu - M N_ 32 )0 4-0Z((o I pG-L <br /> II.Type of Building: (check one) ❑city <br /> I or 2 Family Dwelling-No.of Bedrooms:_'Z ❑Village <br /> ❑ Public/Commercial(describe use): 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 lilt /ZG <br /> A) I. New System 2. ❑ Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numbe s) <br /> Sy stem Tank OnlyExistin S stem --Q k�aDV <br /> B) <br /> ❑A Sanitary Permit was previouslyPermit Number Date Issued issued I <br /> IV.Type of POWT System: (Check all that apply) <br /> XNon-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.Dis ersal/Treatment Area Information: <br /> I.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 /> 3O° 429 432 <br /> 96. o <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 Tanks <br /> VII.Responsibility Statement <br /> I,the undersigned,assume res onsibili for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) •, Plumber's Signature(no stamps): MP/MPRS No. r Business Phone Number r <br /> A �ZS�J <br /> umber's Address(Street,City State,Zip Cook) 1 _L <br /> 27760 3S' Weam Z WI. 54893 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing A nt ignaia ps) <br /> ipproved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination"� �h-1 J� <br /> IX.C n itions f Approval/Reasons for Disapproval: y� <br /> SBD-6398 R07/00 <br />