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Rj <br /> Sanitary Permit Application Safety&Buildings io <br /> visconsin <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Wahingto <br /> Bo. 0 See reverse side for instructions for completing this application <br /> Personal information you provide may be used for secondary purposes Madison,WI 5370 <br /> Department of Commerce [Privacy Law,s. I5.04(I)(m)) (Submit completed form to coup not <br /> state <br /> Attach com tete plans to the county copy only)f9r,the system,on pape=t less than 8-1/2 x 11 inches in size. <br /> County State Sa i19 Parrift Nu er eck if vision to r vious pplication State Plan 1.D.Numbc <br /> MT 5 <br /> I.Appfication Information-Please Pri t all Information Location: <br /> Property Owner Name Property Location <br /> MA1/4 1/4.SIqT40,N,P44E(orl OW <br /> Property Owner's Mailing Address Lot Number 9#eck'iieew4or <br /> 62 01-9rROMA Ra 1 L. 3a S <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> pv�l�iZ to I 5+20 I 952 )SK- 6110 V. J P. 21 o <br /> II.Type of Building: (check one) 0 City <br /> N 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): Town of Gdr <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road lL o <br /> "b <br /> A) 1. ❑New System 2. far Replacement 3. ❑ Replacement of 4. ❑ Addition to Parcel//Tax��Number{s) ? <br /> System Tank OnlyExistingSystem t/L 11 DJ 600 <br /> B) ElI Permit Number Date Issued <br /> A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground ❑Mound ❑ Sand Filter ❑Constructed Wetland <br /> ❑ Pressurized In-ground XHolding 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 /> 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 /> A2 L-0 I3332 X32. 2 �+qM/ '� ❑ ❑ Cl � ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumbers Signature(no stamps): MPMPRS No. Business Phone`lumber <br /> tl Aw aA <br /> umbers Address(Street,Ci ry State,Zip Co e) <br /> Z3-760 3S W£asr W1- 94S93 <br /> VIII. County/Department Use Only <br /> �/ ❑Disapproved Sanitary Permit F (Includes Groundwater Daley <br /> ate ssue Issuing.4 ign re i ps) <br /> l[]fr Approved ❑Owner Given Initial Adverse Surcharge Fee) r�^ /OO v <br /> U Determination lJ�� <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6399 R07/00 <br />