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� <br /> OYl <br /> Sanitary Permit Application Safety&Buildings Division <br /> 201 W.Washington Ave. <br /> in accord with Cotton 83.2 1,Wis.Adm. Code PO Box 7302 <br /> Visconsin See reverse side for instructions for completing this application Madison,WI 53707-7302 <br /> Personal information you provide may be used for secondary purposes (Submit completed form to county if not <br /> Department of commerce [Privacy Law,s. 15.04(1)(m)] <br /> state owned. <br /> Attach complete 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 San' i N - ❑Chet if visio� previous application State Plan I.D.Number <br /> l r,�vn t� �vUCJ <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> '0AVe S erM'eb- 5W 1/4 We'1/4,S 7 T yO,N,1A(orProperty Owners Mailing Address Lott Number Block <br /> 9-1,03r Hanscan, L/c Trw 39 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> �tn bur. !q/1 S�Lfl�'lJ 7,s— x-5-9-3100 INIi�/il �� D <br /> City <br /> II.Type of Building: (check one) ❑ <br /> '3 ❑Village <br /> 24 1 or 2 Family Dwelling-No.of Bedrooms: 0 Town of <br /> ❑ Public/Commercial(describe use): 5 <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearesti <br /> unA) 1. ❑New System 2. ]al Replacement 3. ❑Replacement of 4. ❑Addition to Parcels)S stem Tank Onl Existin S stemf <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued <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 ❑Single Pass ❑Drip Line <br /> ❑At- de ❑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 Rate6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 4_ r 7 �G 3 �> 3 <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> /G 7SD150 1500 2. WGf o ❑ ❑ ❑ <br /> OM G 15vo aC <br /> / ISkt�Fy✓ ❑ ❑ ❑ ❑ <br /> VII.11ponsibility Statement <br /> 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumbaees Name <br /> nn(print)(� Plumber's Signature stamps): MFIMP�R^S No. Business Phone Number <br /> R id,Vt j, O� Nov/L c�f �++1 22 5'S 9_1 7iS 6-(06— <br /> Plumbers Address(Street,City,State,Zip Code) <br /> ,1'77160 //rte P -3,5— W e6_s 'r-- <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Perms IncludesQGrrroouundwater Date <br /> /Issued <br /> �5 Issui ent a ostamps) <br /> $Etpproved 1 ❑Owner Given Initial Adverse Surchargej'l 7—V� <br /> r <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07100 <br />