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ekaonp <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> Visconsin personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce (Submit completed form to county if not <br /> [Privacy Law,s. 15.04(1)(m)] <br /> state owned. <br /> Attach complete plans to the county copy onl r the system,on a er not less than 8-1/2 x 11 inches in size. <br /> County Sta Sani ermit Number Check i revision to p vious application State Plan I.D.Number <br /> I.Aporication Information-Please Print all In ormation Location: U <br /> Property L <br /> Owner Na/{'I&m�ey� Property Location <br /> 06 SnRr- E/K5xl/4/'t //����El/4,5/O TJr) N,R16E or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> z�7 3s� ?7 <br /> City,Stale Zip Code Phone Number Subdivision Name or CSM Number <br /> 'DANFjuft W►_ 54430 IS logia 311(0 Csm U, 02 p. !S3 <br /> II.Type of uilding: (check one) ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> Public/Commercial(describe use): TOST '2 11 Emu. 14q k I own of r 1 < <br /> ❑ State-Owned IzC - % 2q22W <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. ❑New System 1 2. WReplacement 3. ❑Replacement of 4. ❑Addition to Parff�1 Tax Number(s) <br /> System Tank Onl Existing System 53 bal`pT_J <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.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(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 2922 41 5 4176 ,7 rte--- 93, 5- qG-s <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> (04701 6470 nj <br /> ❑ ❑ ❑ ❑ <br /> 10601 loon ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Phtmbees Name(print) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> cl{Aao f(pMw5 j4 ZZS8S1 '71S- $G6- 415 <br /> Pfumber's Address(Street,City,State,Zip C de) <br /> 2--7-1 Go f4 3S I..��Bsr�R , wi• S4 X93 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issum gent Signature(No stamps) <br /> K <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee) 71 17S r 00 11-9- <br /> I` Q 6D 1I r^1��W7 J <br /> Determination --- <br /> J / o t�(J <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />