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safety and Buildings Division county <br /> Visconsin 201 W.Wt�in,Wl 53707-7167. Sanitary <br /> F3vrnG <br /> Mt:digtaH,WI 53702-7162 Smitay Permit Number(m be filled in by Co.) <br /> Department of Commerce ( ) 3151 4-6,54615 <br /> Sanitary Permit Application sea "QLD Number (}� <br /> In accord with Comm 8321,Wis.Adm.Code,Personal mfwmatron you Provide —. <br /> My be mail for scontdery purposes Privacy IaW,315.04(1 XM) Project Addrea(if different it=mailing address) <br /> 1. Applfcatioa Information—Pl ase Print AM Infeimatioa n J�l ( stI/. e- <br /> F Iw <br /> Property Owner's Name Pared 8 lot d Block d <br /> it <br /> ron A ps r <br /> Property Owner's Mailing Address Propoty Location <br /> city,Sate r zip code Plane Number SYL i4 �yti Section <br /> o N Jr 3G 9 bra- zit-4S's ) <br /> D.Type of Building(cheek all that apply) T N, R/ E o <br /> ❑1 or 2 Family Dwelling—Number of Bedrooms Subdivision Name CSM Number <br /> ❑PublicACommercial—Describe Use <br /> ❑State Owned—Describe Use ❑Cuy_❑Vinage ElTownship of TMde �<t <br /> 111.Type of Permit: (Chat,only one hon a line A. Complete rise B if apptieahle) <br /> A. $CtIm System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type ofPOWTSSystem Chat,a6 theta <br /> KNon—Revurmed Infirem l ❑Moud>2A in.of suimbk sou ❑Momd<24 kr.of suitablesou ❑At-Grade ❑Simmgk Paas sandFater ❑ <br /> Constructed Wetland ❑Prassurimd rn-Grmmd ❑Iloldmg Tardy ❑Pat Fitter ❑Aoobk Treomen Unit ❑Recirculating Sad Filter ❑ <br /> Recirculating Synthetic Media Fiber ❑t eechimg Chamber ❑Dile Lam ❑Greve4las Pipe ❑Older(explain) <br /> V.Distinamilfirrisintoneat Area laformatiou: <br /> Design Flow(gpd) Design Soil Application Ratc(gpdsf) Disposal Ara Required(sf) Dispersal Ara Proposed(st) System Elevation <br /> I/S I . Y/ 1 /0 9 ?•s6 /ion rr 9 (Cl iz 9z• o <br /> VI.Tank Info Cap"in Total Number Mmufacum Prefab site Steel Fiber I Plastic <br /> Gallons Gallons of Units Concrete Commented Glass <br /> Nen Emig <br /> Tads Tanks y <br /> Septic in Holding Task /OOtI We.SEf <br /> Aerobic Tremnent Unk <br /> Dosing Chamber !__ <br /> VP.Responsibility Statement-1,tYc. aanamae rmpemiMBly For W WYtM of the POWTS dura a an the attacked phma <br /> Plum s Name(Print)) Plnmba'a MPAIPRS Number Business Phone Number <br /> D r 011, �o /3�6SS -77/s <br /> Plumber's Addr/esss(Street,City,Sank,Zip Code) <br /> SS- <br /> VI .Coma rtment Use osly <br /> Approved ❑DiapprovedSani eery Permit Fee(includes Graudwater Date issued Issuing t tamps) <br /> sFa) 250J 9 <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of ApprovaVReasoaa for Disappsuval <br /> Attack a mphn plain(in the Comity only)far the minas an Paper not lint Man ata x 11 iashta In she <br /> SBD-6398 (R. 01/03) <br />