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cy- U).L� <br /> Not Instpllefc Safe &Buildin <br /> ant ary ermit Application ry <br /> J IREDIn accord with Comm 83.21,Wis.Adm. Code 201 W.Was '.•to• <br /> P►. <br /> isconsun See reverse side for instructions for completing this application ' <br /> Personal information you provide may be used for secondary purposes Madison,WI <br /> Department of Commerce (Submit completed form to co' r <br /> [Privacy Law,s. 15.04(I)(m)] p <br /> state . ;- <br /> Attach <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 -1)2il State �ary,Psrtnit_N'yltnbel ❑Check' r vision to ppe us application State Plan I.D.Nuryby� VI <br /> 1.App[cation Information-Please 'at all Informationerr �� �1( 6-95-3 Location: lkili <br /> ,/f1/ <br /> Property Owner Namen 1!pr Property Location <br /> e <br /> CHALAIi5C/462 1/4 1/4,S 6 T40,N,R6(at <br /> Prope Owner's Mailing Address Lot Number Block Numb. <br /> 12-0- Box 53- 14- <br /> city,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Osteoid W} .64020 __ ( 1715 )75S- 3487S THwJ ,D AM? Tb V. <br /> II.Type of Building: (check one) 0 City <br /> /`� 1 or 2 Family Dwelling-No.of Bedrooms: 0 Village <br /> S <br /> ❑ Public/Commercial(describe use): Town of <br /> ❑ State-Owned Sxkk50a <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road,�j <br /> hutWlzgIRD viz- <br /> A) 1. XNew System2. 0 Replacement 3. 0 Replacement of 4. 0 Addition to Parcel Tax Number(s) <br /> I System l Tank Only f Existing System _ b(A--q,1 -Oct- .30-U <br /> B) Permit Number t Date Issued <br /> 0 A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> Non pressurized In-ground 0 Mound 0 Sand Filter 0 Constructed Wetland <br /> Pressurized In-ground 0 Holding Tank 0 Single Pass 0 Drip Line <br /> ❑At-grade 0 Aerobic Treatment Unit 0 Recirculating 0 Other: <br /> V. Dispersal/Treatment Area Information: • <br /> I.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(Cals./day/sq.ft.) (Min./inch) Elevation <br /> moo boa 0200 . s 612- 6 qq., G <br /> VI.Tank Capacity in Total I #of Manufacturer Prefab Site Steel Fiber. Plastic <br /> Information Gallons Gallons ' Tanks Con- Con- glass <br /> New Existing I crete strutted <br /> Tanks Tanks <br /> - <br /> S IMC 1000 '~- 000 1 jf0.e1�JESCO ❑ ❑ ❑ ❑ ?3:3 <br /> 0 0 0 ' 0 ❑ <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(no stamps): MP/MPRS No. Business Phone Number <br /> illiAeD 1-16R-a5 �� ,� /1/4413. <br /> ?ZS85/ 7/S: - ¢/57 <br /> umber's Address(Street,Ci7eZl p Co e)3s W8'asrm ./ W1- 54893 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater 1 Date ssued ' Issuing Agen Signa re N. s ps <br /> Approved 0 Owner Given Initial Adverse Surcharge Fee) ��//�� / <br /> Determination p�ll�/r 00 Q a2-- • l/� 4''t ' i <br /> IX. Conditions of Approval/Reasons for Disapproval: . - El <br /> rl ~ _Ji; ( �Ar_I <br /> FEB 2 19v <br /> SBD-6391 R07/00 -I L <br /> Teirnl,i-1-- Ey-P? s 1 i_?MEV COUNTY <br /> mNING <br /> 1/-&-05 <br />