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Sanitary'Permit Application Safety&Buildings Divi <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington <br /> See reverse side for instructions for completing this application PO Box 7 <br /> Visconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7 <br /> Department of Commerce Submit completed form to county[Privacy Law,s. 15.04(1)(m)] ( P ty'if <br /> state o <br /> Attach complete plans to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> County a anit Pe i Number ❑ChWif,.�evision o previous application State Plan L D.Number <br /> I.A ication Information-Please Print all Information gyp[ Location: <br /> Property Owner Name Property Location <br /> Kir• 1!4 1/4,S <br /> w <br /> lH T ,N E o W <br /> Property wner's Mailing Address of Number Block Numb <br /> ¢zq2 avl p�Y) <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> G Ali � 6484-o463 3 53 Q AC��S <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 7— ❑Village <br /> ❑ Public/Commercial(describe use): ;Town of '� <br /> ❑ State-Owned K»SA <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road P"OM <br /> A) I. 'ANew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Par el Tax N ber(s) <br /> System TF�umber <br /> Existin S stem 2 Spa <br /> El$) 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 /> Req 'red Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> Z- 1 2 . 7 98.i 100-7- <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 /> A-0776 1000 '' /000 / 1Vj99/✓6sL0 ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> PlumbePs Name(print) Plumbers Signature(no stamps): MP/MPRS No. Business Phone Number <br /> of ,✓ j2S8S/ /S- - /S7 <br /> Plumber's Address(Street,City State,Zip Co e) <br /> 2-77(00 35- WfaM LVI. 54893 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee Includes Groundwater Date Issued Issuin A ent Si�aXusamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) r /��l0 I <br /> Determination v I / <br /> IX. onditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />