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---Wis.Adm. <br /> C 201 W.W Ave. <br /> In accord with Comm 8321,Wis.Ate. Cock Washington <br /> See reverse side for instructions for completing this spp6txtion <br /> V isconsin may be used for Amy purposes Madison,Wl 53707-7302 <br /> Department of Commerce PetSonBi mfOlma110n you protide <br /> ]Privacy Law,s.15.04(lxm)] (Submit completed form to county Snot <br /> state owned.) <br /> Attach complete plans(to the county COPY ody)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> County � Stn Sminay Permit Nmnbw Check(revision to prt:vioua tpplucation Std Plan I.D.NuN (,' <br /> �t^n e W <br /> L Application Information-Please Print all Information Imcatton: <br /> anef- Prepwty I ocanon <br /> t30. 1 rue er #3� 4 1/4 1/4,5/.STyO,N,R (er <br /> Pmpqty wnces Mail Lot block urn <br /> 0.S Tor va/its AVe y� <br /> SheZip Cade Pbooe Number S m <br /> ion Nae or CSM Number <br /> d'S I SS"�2$ ( 'T6? )2-1-067 5 P ��. %� ity UY <br /> IL Type of Building: (cheek one) 13 city <br /> 6 1 or 2 Family Dwelling-No.of Bedrooms: 3 113 a!(t°illage <br /> 13Public/Commercial(describe use):_ <br /> ❑Statue-Owned �¢C-A$btu <br /> Naleu RAS VL_ <br /> FUMN FIVE f� C4Q 3 5-05 <br /> IM Type of Permit: (Check only one box on]me A. Check box on line B if applicable) 8 / /9A) 1. New 2. Replacemeat 3. Replacement of 4. 5. 6. ❑Addition to <br /> Systern System Tank Only Feng Sym <br /> $) Permit Nunn <br /> 13A Sanitary Permit was previouslyissued <br /> IV.Type of PORT System:(Check all that apply) <br /> lB Non-pressurized ht-ground ❑Mound ❑Sand Filter ❑Constructed Weiland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip cane <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Div rsa Xl tment Area Information: <br /> L gn F ow(W 2.Dispersal Area 3.DIVersal Arcs 4.Soil Application S.Percolation Rare 6.Sysmm Elevation 7.Final Grade <br /> Required Proposed Raft(Galslday/sq.R) (Mm./mdt) 7-1 ?1'-fir Q Elevation <br /> YsO 6 Y,?,ck 63 150 , 7 %z 96 .343 /o% So <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons _ Gallons Tanks Con- Coo- glass <br /> New Existing vete strutted <br /> Tanks Tanks <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> 1,the undersigned,assume responsibility for installation of t6 POWTS shown on the attached planL <br /> s am ) P MP No. llunwas Phone Number <br /> j%/ dxr <br /> Plumber's.Address( tree[,City,State,Zip <br /> J� Z 1/.:'71 <br /> DL County/Department Use Only <br /> DisapprovedPermit Fee(Indudw Date Issued i o stamps) <br /> OAppmved ❑Owner Given In(tial Adverse Si trLvge Fee) <br /> Determination 41 250 to *AY <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R 07/00) <br />