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Sanitary Permit Application Safety&Buildings Division <br /> ' In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> ` iseonsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department or commerce l <br /> it b <br /> S <br /> ( umcompeted form to county if not <br /> (Privacy Law,s. 15.04(I)(m)] state owned.) O ` <br /> Attach complete plans to the county copy only)for the system,on paper not less than 8-1/2 x 1 I inches in size. <br /> Countgee Il 1 State Sanitary Permit Numb r ❑Check'f rcvi ' pre ' us ap li ti State Plan[.D.Number �0 <br /> I.Application Information-Please Print all InformMolh I f Location: <br /> Property Owner Name L etLocation <br /> rle-A 6 I,-/G GpVy/4 T37 <br /> N ( ,\ <br /> (or w <br /> Property Owner's Mailing AddressLot Number BI Number <br /> X 363 Li <br /> City,State( <br /> Zip Code Phone Number Subdivision Name or CSM Number <br /> wA k' tr d /S- - Z?&0 <br /> II.Type of Build g: (check one) ❑Ciy <br /> )9 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): Town of r / f' <br /> ElState-Ownedad'e /a, k-e <br /> II1.Type of Permit: (Check only one box on line A. Check box on line B if applicable) �esi Road/ _ 'F pa Y <br /> / <br /> /n <br /> A) 1. ❑New System 2. OCReplacement 3. ❑Replacement of 4. ElAddition to Parcelr Cil ax Num / r <br /> System Tank Only Existin S stem bet(s)S'—O( /()0 <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 N 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.m.) (Min./inch) Elevation <br /> ro <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks `� <br /> Se 047 CV V /� ❑ ❑ ❑ ❑ <br /> v= <br /> X o0 ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement Q <br /> 1,the undersigned,assume res nsibili the for installation of the POWTS shown on attached plans. <br /> Plumbers Name riot Plu bens Signatu ([m mps): MP/MPRS No. Business Phone Number <br /> (S o-e r ✓ ZZ S 171 1 6' V <br /> Piumber's Address(Street,City,State,Zip Code) <br /> CL P 4 D <br /> VIII.County/Department Use Onl <br /> ❑Disapproved Sanitary Permit Fe Includes Groundwater Date I sue Issuing A nt gn c m ) <br /> proved ❑Owner Given Initial Adverse Surcharge Fee <br /> Determination r <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> RLSBD-6398 R07/00 <br /> i <br /> OCT - 3 401 <br /> B.URNETT COUNTY <br /> ZONING <br />