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U <br /> Sanitary Permit Application Safety&Buildings ' sion <br /> 7 In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washing n <br /> Wisconsin See reverse side for instructions for completing this application PO B 2 <br /> Department of Commerce Personal information you provide may be used for secondary purposes Madison.WI 53707 <br /> (Privacy Law,s. 15.04(1)(m)] (Submit completed form to court <br /> Attach tom tete lans to the conn co onl )for t s stem,on a er t less than 8-1/2 x 11 inches in size. state ) <br /> County State Sanitary etmit N der ❑C c if:ekition to,previous plication State Plan 1.D.Number <br /> I.A ication Information-Please Print Il It formati n <br /> Property Owner Name Location: <br /> LA.50M <br /> Pr et y Lotation <br /> Property Owner's Mailing Address l/4 1/4,S.7—ST ,N, ,75E or W <br /> 401 l "C 'dn1 Lott Number Block Number <br /> City,State t, Zip Code Phone Number ` <br /> Subdivision Name or CSM Number <br /> D%U,F- I GO 1-72- 630 )893 4g4q V 2 /4 <br /> I),.Type of Building: (check one) ❑city <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> (3Public/Commercial(describe use): Town of <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road n <br /> A 1. ❑ New System 2. p LW�NdW • <br /> Y �Re lacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numbers) <br /> B System I Tank Only --.Existing System 0 ds DO <br /> ed <br /> ❑A Sanitary Permit was previousIv issued I <br /> Permit Number Date Issu <br /> KIV Type of POWT System: (Check all that apply) <br /> on-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass <br /> ❑At-grade C3 Aerobic Treatment Unit ❑Recirculating ❑ Drip Line <br /> ❑Other: <br /> V.Dis ersal/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 /> Req�jrred Proposed Rate(Gals./day/sq.ft.) (Min./inch <br /> 300 Q,2� Elevation <br /> 111 ) <br /> 4�Z .1 93. 4 9 6_ <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 trete strutted <br /> Tanks Tanks <br /> s£ C �sb �� ❑ ❑ ❑ ❑ <br /> � s� 1-1 ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached tans. <br /> Plumber's Name(print) Plumber's Signature(no stamps): bIP/MPRS No. <br /> Business Phone Number <br /> lFlGis<Ai2D t/,✓ — 22S"8S� S- /S7 <br /> umber's Address(Street,City State,Zip Co e) <br /> 2- 760 3S W56m Wl• 54893 <br /> VIII. County/Department Use Only <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groun water Date Issued <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee) Issuing A nt Si atu stamps) <br /> Determination 60/ D <br /> IX. Conditions of Approval/Reasons for Disapproval: <br /> rah �Id ci1I1 Se to 6-0 try Uo(r 9 PA. 13b <br /> &4 <br /> SBD-6398 R07/00 <br />