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IV 600 Jw <br /> Sanitary Permit Application Safety&Buildings D ion <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W. Washingto <br /> `�sconsin See reverse side for instructions for completing this application PO Bo <br /> W. <br /> Dppartment of commerce Personal information you provide may be used for secondary purposes Madison,WI 5370} <br /> [Privacy Law,s. 15.04(t)(m)) (Submit completed form to coun n t <br /> Attach com tete lans to the coon co v onl )for the system,on paper not less than 8-1/2 x I 1 inches in size, state o ) <br /> County State Sanita a 't <br /> UPS e ❑Ch ifre to previous plication State Plan L D.Numbcr <br /> I.A ication Information-Please Print Il Information �� <br /> Property Owner Name Loeati0rt: <br /> �A�t n .rt r Property Location <br /> Property Owners'Mailing Address G1 1/4 1/4.S�di' <br /> g(0 MA 4`0 I Lot dumber It Block umber <br /> City,State Lip Code 7- t7 <br /> _PA'v &4$�° Phone Number Subd'vision Name or CSM um r <br /> � t s > 2 <br /> II.Type of Build ng: (che(k one) <br /> >14 1 or 2 Family Dwelling ❑City <br /> -No.of Bedrooms: <br /> ❑ Public/Commercial(describe use): 0?ow t❑Village <br /> Village <br /> ClState-OwnedoytKn <br /> III. Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road 11 <br /> A) 1. ❑New System 2. pp n5 c-r <br /> �7Re lacementL10�Re lacement of 4. ❑Addition to Parcel Tax Numbers) <br /> 5 stem nk Onl Existin System 0���7-.VV T S to <br /> B) Permit Number <br /> ❑A SanitaryPermit was reviousl issued Date Issued <br /> IV. Type of POWT System: (Check all that apply) <br /> KNon-pressurized In-ground ❑ Mound <br /> ❑Pressurized In-ground ❑Sand Filter ❑Constructed Wetland <br /> Cl At-Rrade ❑ Holding Tank ❑ Single Pass ❑ Drip Line <br /> El Aerobic Treatment Unit 13 Recirculating 11 Other: <br /> V.Dis ersaUTreatment Area Information: <br /> I.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area - <br /> Re uired s 4•Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> ,.� q� Proposed Rate(Gals./day/sq.ft.) (Min./inch) <br /> /_[t. .� ^_ Elevation <br /> wT 9�. o +- q(0- Ci <br /> VI.Tank Capacity in Total 4 of Manufacturer <br /> Information Gallons Prefab Site Steel Fiber- Plastic <br /> Gallons Tanks Con- Con- <br /> New Existing glass <br /> Tanks Tanks trete strutted <br /> (7Ql�J�St%D tt000 l0�0 IJOIZWEScc, ❑ ❑ ❑ ❑ <br /> VII. Responsibility Statement <br /> 1,the underst tied,assume res onsibility For installation of the POWTS shown on the attached fans. <br /> Plumber's Name(print) Plumbers Signature(no stamps): IvIP/MPRS No. <br /> rr �' _ �+ Business Phone lumber <br /> III umber's Address(Street,City State,Zip Code) I ���J/ S �,�7 <br /> 277/0 3S W�ssr::x WI. 54893 <br /> 71 <br /> VIII. County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee Includes Groundwater <br /> Eroved(3 -------- <br /> Date Isued <br /> Owner Given Initial Adverse Surchar a Fee Issuing.4g t igna re m <br /> g ) <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />