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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 /> `�SCOnSin See reverse side for instructions for completing this application PO Box 7302 <br /> Department of Commerce Personal information you provide may be used for secondary purposes Madison WI 53107-7302 <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 State� anitary Permit Number heck if revision to pre 'ous application State Plan I.D.Number Ltn�F� O1 <br /> I.Application Information-Please Print all Information( Location: <br /> Property thvner Name Property Location <br /> Dean & Nancy Swanberg SE 1/4 NE 1/4,s 1 T37 N,d84or)w <br /> Property Owner's Mailing Address Lot Number Blber ock Num <br /> 22297 Marek Road na na <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Frederic WI 54837 ( 715 -)327-8245 na <br /> II.Type of Building: (check one) ❑City <br /> W 1 or 2 Family Dwelling-No.of Bedrooms: ?_ ❑Village <br /> ❑Public/Commercial(describe use):_ j(1 Town of Trade Lake <br /> ❑ State-Owned <br /> Nearest-R-1. Marek Rd <br /> Parcel T xxLNuumber _ <br /> 1,3nj-01 700 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. LX Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> R 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 S.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 300 750 750 .4 na 1 93.70 95,75 <br /> VII.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 /> 750 -- 750 1 EWIeEserConcret <br /> VIII.Responsibility Statement <br /> 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) APlees Sign (no 6 ps): MP/MPRS No. Meigna—tu <br /> Donald Daniels MP 330/221593 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO Box 316 Siren WI 54872 <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination 2 � d(�of Approval/Reasons for Disapproval: 1,30 * <br /> SBD-6398(R.07/00) <br />