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II Uvf„c r lU uc r v<f <br /> !L::�* <br /> �lasm n <br /> 11 L <br /> Department of Commerce (608)_'nn-,I51 'l/L/UB�y,I-�,-f1 <br /> I' <br /> Sanitary Permit Application State Plan I.D.Number <br /> In afford with Comm 8321,WI&Adm.Code.personal information you provide <br /> may be used for secondary purposes privacy Law,815.04(lxm) <br /> Project Address(if different than mailing address) <br /> I. Application Information-Please Print AB Informatioa G/frrr l�P / TI QC <br /> Property Owoer's Nameen <br /> Parcel# Lot# <br /> Block# <br /> 36 — 61 co <br /> PrOpAly owvc'a Mailing Address <br /> OProperty Location Lc)T <br /> City.State Zip Code Phone Number yti _,/, Seen._ V <br /> 1:634?5t? <br /> II.Type of Buil (check all that apply) /S v T N; R/ le one) <br /> or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Numberm <br /> blic/Comeroial-Describe Use 6r� ' WU -670 U' / . <br /> ❑Stare Owned-Describe Use ❑cityOVillage Afownship of ,V <br /> c <br /> III.Type of Permit: (Check only one box on line A. Complete fine B if appBcable) <br /> A. New System yst ❑ Replacement System ❑Treatment/Holding Tank Replacement only ❑Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Chan of List Previous Permit Number and Date Issued <br /> BC Permit Transfer to New <br /> Before Expiration plumber Owner <br /> IV.T of POWTS S stem: Check w that apply) <br /> jff- Ion-Pressurized Is-Ground ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil ❑At-Grade ❑Single Pass Sand Fil; ❑ <br /> Constructed Wetland ❑Pressurized In-Ground ❑Holding Tank ❑Pest Filter ❑Aerobic Treatment Unit ❑Rex7reulating Sand Filter 13Recimdatm Synthetic Media Filter (3 Leaching Chamber o Drip Lice 13 Gravel-less Pipe ❑Other(explain) <br /> V.Dia raal/Trestment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(si) Dispersal Arra Pro ed s S <br /> _?o41? Pes (t) ystem Elevation <br /> 32 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site $tall <br /> Gallons Gallons of Units Fiber Plastic <br /> New Existing Concrete Constructed Glass <br /> Tanta Tanks <br /> Septic or Holding Tank 7� <br /> teW <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Respungjbility Statement-4 the undersigned,sun responsi ' for installation of the POWTS shown on the attached pian <br /> Plumber's Name(Pont) Plumber's Si WIMP LS Number <br /> Btuimess Phones. <br /> Number <br /> John Solofra #223779 715-376-2278 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO Box 161; Gord(n, WI 54848 <br /> VIII.Count /Departmanst Use Only <br /> Approved ❑Disapproved S111111try Pemtit Fee(includes Groundwater Date Lanett Lvatimg igmamtre a) <br /> iJ 9p <br /> CJ Owner Given Reason for Denial Surcharge Fee) 64 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plain(to the County only)for the system on paper not Ips than 81/2 x 11 inehn ins <br /> SBD-6398 (R. 01%03) <br />