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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> 1 See reverse side for instructions for completing this application PO Box 7302 <br /> `�sconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned. <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 Stat Pylmit Number ❑Che if revi ion tp Qrevio psla�p' ation State Plan 1.D.Number <br /> 1F <br /> I.Apacation Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> 1/4 1/4,S T40,N,R14or W <br /> Property Owner's Mailing Address Lot Number Bhekaltmt6er <br /> Iq COON RAPIDS VD Lo'f't✓ M :Z U•t- <br /> City,State Zip Code Phone Number l,7 lq�s Subdivision Name or CSM Number <br /> CMCJ R"jDS M 4 , 55433 f Sir► 42A-3 G <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village �^� <br /> ❑ Public/Commercial(describe use): `Town of . All <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) I. kNew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numbers) <br /> System Tank OnI3 Existing System B -&1 3 - G1 a 7 00 <br /> B) <br /> 13 Permit Number Date Issued <br /> A Sanitary Permit was previously issued <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 /> 45o9 oo Cleo '.5 ------� q4-0 46 .6 <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 /> ❑ ❑ ❑ ❑ ❑ <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) Plumber's Signature(nos s): MP/MPRS No. Business Phone Number <br /> 1►A� �bt'was L%4^ .,t 2zS8Si Its-8W6- Ms <br /> lumber's Address(Street,City,State,Zip de) OO <br /> 09-1 <br /> VIII.County/Departmen se Only <br /> ❑Disapproved Sanitary Permit Vp(Includes Groundwater Date Issued Issum A ent Si a o stamps) <br /> proved ❑Owner Given Initial Adverse Surcharge Fee �l <br /> Determination 1 f <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />