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SCO sin /I�1fv ��^lll[� <br /> Department of Commerce (008)2t)6 �l5l 1-017q <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 93.21,alts.Asim.Cade,personal information ym provide 07 51 <br /> may be used for secondary purposes Privacy Law,s15.04(lxm) Projece Address(if different than mailing address) <br /> L Application Information—Please Print AB Information <br /> SOwner's Name Passel# Lot# Block# <br /> oh J ho aa- I 6 -.511& -6 300 <br /> Property Owner's Mailing Address Property Location <br /> ocatiGo V'f-,( _TS 10-4 <br /> Ua1-15� Q V, _V, Section�- <br /> City,State'// 'p Code Phone Number '/ <br /> / '" r — � � T T�N; R/7(cycle one) <br /> II.Type of Building(cheek all that apply) <br /> ❑1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name ' CSM Number <br /> Public/Commercial-Describe Use �7� <br /> (3 State Owned-Describe Use ❑City_Qvil age 61t owaship of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. #rqcw System ❑ Replacement System ❑TteatmenNHolding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑ Permit Rcnewal ❑Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS S stem: Check 211 that apply) <br /> tons <br /> u-Pressurized inGround 13Mound>24 in.of suitable soil (3Mound<24 in.of suitable soil (3At-Grade ❑Single Pass Sand Filteruetad Wetland ❑ Pressurized InGmund 13 Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line C3 Grovel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdaf) Dispersal Area Reef <br /> (st) Dispersal Arta Proposed(sf) System Elevation <br /> 3 7e, • '7 3 3 9 3 4 76 1 93,194 G,0 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tama Trots s,[ <br /> Septic or Holding Tank S V Q••y Sq�_ 1� <br /> Aerobic Treatment Unit <br /> Dosing Chamber Gn `OOv `„ <br /> VII.Responsibility Statement-1,the undersign u re illty for Installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Prim) Phrmber's NP/ RS <br /> Number <br /> Business Phone Number <br /> John Solofra #223779 715-376-2278 <br /> Plumber's Address(Street,City,State,Zip Code) f ` <br /> PO Box 161; Gordon, WI 54838 <br /> VIII.Cimny/D!partment Use Only <br /> ❑Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater /Date Issuing Sigaat ue tamps) <br /> Surcharge Fee) /1 0/ 1/ 6 6 <br /> owner Given Reason for Denial V <br /> VL Conditions of Approval/Reasons for Disapproval <br /> Resii.7'S of Erj: UW rr Visi�& :J&j/ be S,b,lf/1762 <a 4.41 'r 6vW7X <br /> W54L As T06 XXCPAWWX Of- 6iUAaC*—,-, <br /> Attach complete plans(to the County only)for the system on paper not Ins than 81/2 c 11 inches in size <br /> SBD-6393 (R. 01103) <br />