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�:_ lid o_ .dn p <br /> ls. QU 1'/Ie <br /> 1sconsinP+I_d.scr. tt l 5 Vin, o s Paan l\ n <br /> Department OfCOmmerce (608)266.3i51 �7 + 7L <br /> Sanitary Permit Application <br /> Sine Plon I D Number <br /> Iii acea.d with Comm 83'-1,Wis.Adm.Code.personal information you prusida <br /> PAnmay be used for secondary purposes Prsacy taw,s;5 04(1)(r•.) PrgiCLt Aduresi;i(diI(ercn::nen.mc;L::e set:e.y <br /> lication Information-Please Print All Information <br /> y� <br /> Owner's Name Parcel h Lot a Blocka3s6 /eCie y/�,p 04700 Owner's Mailing Address Property Location <br /> 6ar/ rr-.t i tat 60> .LOTte Zip Code Phone Number —A• —�• Section �o <br /> adbor mN S ��— /d3b �uj�ny (circleo <) <br /> e of Building(check all that apply) IsT N; RE orf Family Dwelling-Number of Bedrooms is Subdivision Naa�m�^e, / CSM Nummber/Commercul-Describe Use l-�rn L� I isqwned-Deunb<Use DCiry_O Village(Township of SCO tr <br /> rNe. <br /> of Permit: (Check only one box on line A. Complete line B if applicable) <br /> ew System a Replacement System DTrcatment/HoldingTank ReplacementOnly C OtherModificanon to Existing System <br /> ermit 0.enewai ❑Permit Revision ❑Chane of C PTfLisr Previous PcanitNumberanC Damissced <br /> re Expirationf POWTS S'stem: Check VI that a 1 ssurized In-Ground LJ Mound>24 in.ofsuiiabie soil C ,(bund<24 in.of suuaoie soil L At-Grace LJ Single Pass Sand F;acr Wetland D PressumedIn-Ground CHoldingTank LJ Pct Filler C Aerobic Treatment Unit C RecirculaiimgSandFlhe-g Synthetic Media Filter D Leaching Chamber D Dri Line C Gravel-less Pipe D Other(explain) <br /> V.pis ersat(Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Ratel gpdsq Dtspersai Area Required isf) Osresai Area Proposed(st) System Linx:o. <br /> Sap 5 600 6&V 9y9 93.y <br /> %1.Tank Info Capacity in Tota, Number M.nuf=—C, Prefab Site Saes F:Der P- <br /> Gallons Gallons of Units Concrete I Constructed I -s'., <br /> New auring <br /> :ass <br /> TarJcs TTanis <br /> Septic or Holl dmg TaN <br /> Aerobic Tirso x L'rui <br /> Dosing Chamber Sr70 SOO <br /> X11.Responsibility Statement- 1,the undersigned.assume responsibility for Installation of the POINTS shown an the attached plans. <br /> Plumber's Name(P�'rin//t) Plumber's�Signatu/re/ MP'MPRS Number Business Phone Namber <br /> I?,r/c �7o Fra. f /?-c v�ti. <br /> Plumber's Address(Sleet.City.State,Zip Cade) <br /> 776 /w 3.r- WE�S�r� call S5'8`�3 <br /> X711.Countv/De artment Use Onl <br /> Approved D Disapproved Sanitary Permit Fee Imciudes Groundwater I Date Issued Issuing ent Signam¢(N S,amps; <br /> Surcharge Fee) <br /> ❑Owner Given Reason(or Denis1 sv-1✓.) j r1/r/..^C. <br /> IX.Conditions of Approval,Reasons for Disapproval <br /> � NI _-, lil��Y LLL�Y ' <br /> Much complete plan Ito the Calmly only)for the system oa paper not kit than 8112 a 11 iathn in sic <br /> SBD-6398 (R. 01/03) <br />