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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> SCORSin <br /> Department of Commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to cotmTy if not <br /> state owned. <br /> Attach com fete lans to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> county State SanitaryPermit Number ❑Check if revision to previous application State Plan 1.D.Number AM <br /> 33L1013 ( - <br /> I.Application Information-Please Print all Information Location: J <br /> Property Owner Name <br /> �� Property Location <br /> W <br /> RO4 �1C A4 1/4 1/4 S T N,REE or <br /> Property Owner's Mailing Address Lot Number -41aQwhim6er <br /> 1592Po?' sr_ N.W. z <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> ANNA W.- &12- 2 V.+ b <br /> I)[.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): ATown off n�- <br /> ❑ State-Owned L*OLLE71€ <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. X New System 1 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number( <br /> System Tank Only Existing System 1 dl -0 <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> UNon-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.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) 44.-1 Elevation <br /> 45o 643 g .7 194. 4 .o <br /> VI.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 Tanks <br /> 4(s R b$ I Shy,/ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> tk olw f}vvk,tJS 22S8S1 115• Swo- 4ts-i <br /> Plumber's Address(Street,City,State,Zip Code) <br /> �� t. 3S Isr LJt . 54893 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing A nt S' store o <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee2}Ifi � 66 2 .2O D l <br /> Determination ,� LAJ' J <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> S13D-6398 R07/00 <br />