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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 /> N iseonsin Personal information you provide may be used for secondary purposes Madison,Wl 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 compTete plans to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> County State Same P 't Number ❑Ch k,if revisi to revious pplication State Plan D.Numb r <br /> L Application Information-Please Print a 1 forma oo Location: <br /> Property Owner NamePrope ciuiyg ,r // f <br /> S t, p 6---% )A0/Q((// ��TO, <br /> S 1/4 S� N Rr� o W <br /> Property Owner's Mailing Address Lot Number �n nBlloockk Number <br /> ,P-.)L3 E a` 44-" e <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> SO . 'f Paul, WK S0-7 S SI SSS �78/ <br /> II.Type of Building: (check one) ❑City <br /> (>lf 1 or 2 Family Dwelling-No.of Bedrooms: — ❑Village <br /> 13Public/Commercial(describe use): [Town of <br /> ❑ State-Owned Ceel335- <br /> 111.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearer Rotd 3 <br /> A) 1. ❑New System 2. %Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s)S stem Tank Onl Existing System Q — —a P O <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit 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 C7 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) i Elevation <br /> 0o roc /3 l r `t3 r -7 <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 /> of ❑ ❑ ❑ ❑ <br /> O ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibilily for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) PImbds Signa e( stamps): MP/MPRS No. Business Phane Number <br /> (S v ZZ Sz 2 9 7/ Cr�6PJ <br /> Plumbers Address(Street,City,State,Zip ode) <br /> Cd t:�. �� <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Is red Issuing cnt 'gnawre(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fe ) r l� <br /> Determination ��.•l�' <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 --rr <br /> J 0i <br /> Oct 31.001 <br /> B.URNETT COUNTY <br /> ZONING <br />