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ao 3/�8 �z- <br /> Sanitary Permit Application ety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> Visconsin <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(1)(m)] (Submit completed form to county if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the s stem,on paper rlot less than 8-1/2 x 11 inches in size. <br /> Coun State Sanitary Permit Nu her ❑Chec if revision to previous plication State Plan I.D.Number <br /> 0/1N e— 3 0t.�a s A- <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location /` <br /> C / A < <' /� ['C 1/4 1/4,S T�/O N,Rr�E(or) <br /> Property Owner's Mailing Address Lot Number Block Number <br /> ,60 X 2 7 3 090 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> t <br /> / 1 A o n A) 5S $' ( �o )a33- 67 © �'qN d �jd/ es <br /> II.Type of Building: (check one) ❑City <br /> t1 or 2 Family Dwelling-No.of Bedrooms: 12 ❑Village <br /> public/Commercial(describe use):_ IW-Town of C// <br /> ❑State-Owned ©A'k//�/�Com` <br /> Nearest Road /k <br /> Parcel Tax Num s) 5 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. New 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> EKNon-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 /> o ya c/ g o qs97 <br /> VII.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 /> I I I±i 1 ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name rint) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> y5�a/n� td -2G9/ y9-7� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit a(Includes Groundwater Date suedQIssuing Agent Sig <br /> Pproved El Owner Given Initial Adverse Surcharge Fee) <br /> 1 Determination � d27 � <br /> X.Conditions of Approval/Reasons for Disapproval: / <br /> i <br /> SBD-6398(R.OB NETT COUNTY <br /> 7nxnair. <br />