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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W Washington p0 Box 7302 <br /> ��5coff5in See reverse side for instructions for completing this application <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 9j <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paKr not less than 8-1/2 x 11 inches in size. <br /> County State anitary Permit Number eck if vi ion to prevt us application State Plan I.D.Number <br /> nE 5Sg e <br /> I.Application Information-Please Print all Information k. Location: <br /> Property Owner Name Property Location <br /> 617 L un �n �rQ'��S �/E 1/44YF 1 A,S 26TJ-'1N,R/CF(W. <br /> Property Owner's Mailing Address> Lot Number Block Number <br /> i c3s LvaC/an <br /> City, to Zip Code Phone Number Subdivision Name or CSM Number <br /> AMCenG 5�/���/' ( '`1i ) 3z tel- <br /> II.Type of Building: (check one) ❑City <br /> W 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑Public/Commercial(describe use):_ )4 Town of <br /> ❑State-Owned //'QCK/& <br /> Nearest Road f J <br /> G[1sxGrC1�-'+ �a1 <br /> Parcel Tax Number(s)o -3% <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. W Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> $) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> Er Non-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.Syste Elevation 7.Final Grade <br /> Requireddr Proposed Rate(Gals./day/sq.ft.) (Min./inch) �/ !?7,?n Elevation ,c, <br /> lJ� ✓Z> pC19i� � r "' 7;-1 O / rpt) 9�•�/ <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 I Tanks <br /> 13 <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Pl 's Name(print)/ Plumb/�r' Signatu ( tam ): MP/MPRS No. 7Busincss Phone Number <br /> DX� 3 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 3J Z //5->Z4 -5-/ it c -117 <br /> IX.County/Department Use Only <br /> �� ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin Signature s s) <br /> .Q Approved 1 ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination Ti1� <br /> X.Conditions of Approval/Reasons for Disapproval: I ,1 <br /> JUL 1 2 204 <br /> BURNETT COU <br /> 4UNING <br /> SBD-6398(R.07/00) <br />