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P �Q.6L ,r1 397 <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> ` ISCOnsinsee reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce Submit completed form to <br /> [Privacy Law.s. 15.04(1)(m)] ( P county if not <br /> state owned. <br /> Attach co lore lens to the county copy on] for system,on paper less than 8-1/2 x l 1 inches in size. <br /> County state Sari Permi ber ❑C if rev�ision�(o iou a lication State Plan I.D.D.Numb i h <br /> I.Application Information-Please Priv all Information <br /> FF oo�C Location: V� <br /> Property Owner Name Property Location AA ( <br /> 1/4 1/4,S4 T ,N 7E o&^W) <br /> Property Ownces Mailing Address Lot Number 111uc"hweler <br /> 7-4-5 47- G�Zr <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> R WI S4g77- 3 s79 <br /> II.Type of Building: (check one) ❑City <br /> I or 2 Family Dwelling- ibe of Bedrooms. Z' ❑ own of <br /> iliage <br /> ❑ Public/Commereial(describe use): <br /> ❑ State-Owned 14 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. ❑New System 2."Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System I Tank Only Existing Sy-em <br /> B) Permit Number Date Issued <br /> El Sari Permit was previouslyissued <br /> IV.Type of POWT System:(Check all that apply) <br /> :PNon-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 /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Arca 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final <br /> 3 Required Proposed Rate(Gals.day/sq.AJ (Min./inch) ql-7 9 x y Elevation 0O <br /> OD S5 / 1.+.L,) S• 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 trete strutted <br /> Tanks Tanks <br /> SF.Rtc ~- J KRj✓ ❑ ❑ ❑ ❑ <br /> -7 ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I the undersigned,assume rres ility for installation of the POWTS shown on the attached plans. <br /> Plumbees Name(print) Plumber's Signature(no ps): MP/MPRS No. Business Phone Number <br /> c 225851 7" 866- MSS <br /> umbers Address(Street,City,State,Zip C ) <br /> 23760 tf±4 3S tj6mg Wi- 54893 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit F (Includes Groundwater Date Issued Issuing Aught Si to ) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) 7 D d <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />