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S'an;bey Permk Application <br /> In accord with Comm 83.21,Vs.Adm. Code 2Ul W. Washington Ave. <br /> 01sconsin <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 (� <br /> Department of Commerce [Privacy Law,s. 15.04(Ixm)] (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 /> )xnty State SP r it Number ❑ eck if revision to previ application State Plan I.D.Number <br /> Application Information-Please Print all Information Location: <br /> operty Owner IT: Property Location <br /> IT: <br /> S�ShAA /4,S T N,R19(or)W <br /> operty Ownees Mailing AddrM Lot Number Block Number <br /> ity,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 53'8 3 3c ) <br /> 1.Type o uilding: (check one) r ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms:-3— 11 Village *4,b <br /> - O_ Q <br /> I ublic/Commercial(describe use):_ Town of J� <br /> I State-Owned <br /> Ne st R <br /> Vd <br /> Parcel Tax Numbers _ as <br /> [I.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. KNew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> $) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> V.Type of POWT System:(Check all that apply) <br /> I Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> I Pressurized In-ground WHolding Tank ❑Single Pass ❑Drip Line <br /> I At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> F.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application S.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(GalsJday/sq.ft.) (Min./inch) Elevation <br /> SII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> nformation Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strtrcted <br /> Tanks I Tanks <br /> ❑ ❑ ❑ ❑ ❑ <br /> /III.Responsibility Statement <br /> I,the undersigned,assume responsib7ity for installation of the POWTS shown on the attached plans. <br /> um is Name(print) 1 Ps S' lure(no stamps): MP RS No. Business Phone Number <br /> -e -1 2.2174 7(5'— 351 <br /> lumber' ddress(Street,City,State ' Code) <br /> lie 4n SFz <br /> .County/Department Use Only <br /> ❑Disapproved I Sanitary Permit Fee(Includes Groundwater Date Issued Issum gent Signature(No stamps) <br /> Xpproved ❑Owner Given Initial Adverse Surcharge Fee) <br /> \ Determination <br /> C.Conditions of Approval/Reasons for Disapproval: <br /> ID-6398(R.07/00) <br />