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C"12C[17yp <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> `�seonsin See reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for secondaryMadison,WI 53707-7302 <br /> Department of Commerce [ rivacy Law,s. 15.04(I)(m)] Purposes (Submit completed form to county if not <br /> state owned. <br /> Attach complete lana to the coup co only)for the s stem on r not less than 8-1/2 x i l inches in size. <br /> C0un1Y State er k if viai to previous application State Plan I.D.Number <br /> I.Apidication Information-Please Print all Information Location: <br /> Property Owner Name Property Location q <br /> T ,N E <br /> 1/4 W <br /> Property Owner 2 <br /> 1/4 S Mailing Address Lot Number tv\JII <br /> 2 al3 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number 44 <br /> KCVU19 MN Seo44 7V-1 V 17 - lam- � <br /> i��(describe <br /> (check one) ❑City <br /> ling-No.of Bedrooms: �� Village <br /> ibe use): JqTownof <br /> ❑ State-Owned OMIAAAG <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road IW. RO. <br /> A) 1. *New System 1 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to P� Tax N er(s) <br /> System Tank OnlyExistin System b <br /> B) Permit Number Date Issued <br /> C3 SanitaryPermit was previouslyissued <br /> IV.Type of POWT System:(Check all that apply) <br /> id"-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank 0 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 Arca 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Reqldred Proposed Rate(GalaJday/eq.R.) (Min./inch) 0.� Elevation <br /> 1664S I 1 �- 96. <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 settcted <br /> Tanks Tanks <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> 1,the undersigned,assume m9nnsibility for installation of the POWTS shown on the attached plans. <br /> Plumbers Name,(print) Plumbers Signature(no ): MP/MPRS No. Business Phone Number <br /> ��,��,� lln �s2Zs SS/ �s6-415 <br /> Plumber's Address(Street,City,State,Zip ) <br /> ;7-1?60 ti s k/ yr�e M.548y3 <br /> VIII.County/Department Use Only <br /> ❑Disapproved I SanitaryPermi (Includes�dwater Date I uedt e) <br /> R.Approved 13 Owner Given Initial Adverse Surcharge Fee) <br /> Determination Z Q <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />