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W15consin 4,7)� z 1 <br /> (eon) r� �l�l <br /> Department of Commerce Stan; Plan LD.Number <br /> Sanitary Permit Application , <br /> In accord with comm 53.21.Wier.Adm.Code,Personal information you trialProf Address dd (if different it=mailing addiaa) <br /> may be unit for secondary Ptnpom Pill Law,at 5.0411)(m) . <br /> L Applical loformadm-Pleme Print All Informtiml,", /7 /_; �e]r�/ <br /> ((.�� `r'1, Parcel# La# Block At <br /> Property O"'ne's Name ,f6a 41/ -oz7OC <br /> AJ,•, [,o v `C '-- Property Locan6 <br /> Property Ow al Mailing Add'as }/1� �L <br /> tot Rd LL"_Y, 3i---y'+ dna 17 <br /> Zip Code <br /> Phone Number <br /> city,Starnl,JT. svdo ITx. �f G'1J-10 o R y(circlecoe) <br /> S 0D HCl —� <br /> II.Type of Building(cheek all that apply) Subdivision Name CSM Number <br /> 91 or 2 Family Dwelling-Number of Bedrooms <br /> 0Public/Cotnnci l-Describe Use 0CityQViSageawm1upofSGf-1 <br /> ❑State owned-Describe Use <br /> Ill.Type of Permit: (Check only one boa on Boe A. Complete Hue B if applicable) <br /> A. CrNew System ❑Repiacemrnt System ❑TrutmrnNiiolding Talc Repiacemrn[Only <br /> ❑ Other Modification in Existing System <br /> 13 Change of 13 Peau[Transfer to New <br /> List Previou Permit Number and Date Issued <br /> B. ❑ Permit Renewal 13 Permit Revision Plumber Owner <br /> Before Expiration <br /> 1��V.T//�� of POWTS S tem: Check all[hat a 1 ❑Sin a Pass Sand Filter 13 <br /> AVIOn—Pressuriad 1n.Ground ❑Mtm > <br /> od24 inti.of suitable soil ❑ Mound<24 in.of suitable soil ❑Unit t ❑Recirculating Sand Filter <br /> a 61 <br /> Construce d Wetland ❑Preuurixed la-Gro d ❑Holding Tank ❑Put Filter ❑Aerobic Truunent ❑ <br /> Recirculating Synthetic Media Fitter ❑LoathingChamber <br /> (]Drip Line 0 Gavel-leu Pipe ❑Other(=Plain) <br /> V.Dig reatment Arm Information: ersat Arta Required(sf) Dispersal l AProposed(at) System Elevation <br /> Design Flow(gpd) Design Soit Application Rate(V&f) DL er 3 Z 96.0> <br /> 3 60 r Manufacturer prefab Site Steel Fiber Plastic <br /> VI.Tank Info Capacity in Total Number Concrete Constructed Glass <br /> Gallons Gallons of Units <br /> New Existing <br /> Trod¢ Tanks <br /> Septic or Holding Tank <br /> Aembie Treatment Unit <br /> Dosing CWmber <br /> VII.Res nsibility Stat rot-L the undersigned.mum rapomibtRty for installation of the POWTS shown on the attached plans. <br /> MP/MPRS Number Buainae Phone Number <br /> Pi s Name( Plumber's Sigmuue _ <br /> Ksop / 35= <br /> Plum 'SA (S iry,Sate,Zip Coda) 1 �'�c / iC <br /> n o c 1 V <br /> Coen rtment Useclde Date lsmmd issuing illustrate a) <br /> Sanitary Pettnit Fee(inu�7Grotmdwater 'I <br /> Approved ❑Disspproved social I=) <br /> ❑Owner.Given Resson for Denial <br /> UL Conditions of ApprovaUReasons for Disapproval <br /> Aaxh complete plain(to the Cwery only)for the sysrem on paper vol less than gIR s Is incho inti stet <br /> SBD-6398 (R. 01 03) <br />