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6D <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> 'n <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> Nvisconsin Madison,WI 5]3707-7302 <br /> Department of Commerce Personal information you provide may be used for secondary purposes f <br /> [Privacy Law,s. 15.04(l)(m)] (Submit completed form to county if not <br /> state owned. <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x I I inches in size. <br /> Stlaniq Permit N 13 Check if revision to pr`�vious application State Plan 1.D.Number <br /> County A ff I C _2 <br /> I.Application Information-Please Print all Inforthation Location: <br /> Pmporty O�r Name Property Location <br /> 195-�f r OlLi-5 �,F 114 IVF114,S.10 T3eN,R)_(E(or)�Q <br /> Property Ownees Mailing Address Lot Number Block Number <br /> ,570340 k-et)t LIK Rd- _�P_hcac Number <br /> city,state Zip Code Subdivision Name or CSM Number <br /> Fredr-ieAr , W_T� 1 -5_*93�7 ( Vs- 0�3 90 V/fe r-#-5 <br /> 11.Type of Building: (check one) 0 city <br /> V( I or2 Family Dwelling-No.of Bedrooms: 0 Village <br /> • Public/Commercial(describe use): 21 Town of <br /> • State-Owned L4 Foo((e"Me <br /> 111.Type of Permit: (CheekonlyoneboxonlineA. Check box online B if applicable) Nearest Road Ll-enf UK. Rd' <br /> A) 1. 0 New System 1 2. AReplacement 3. 1:1 Replacement of 4. 0 Addition to Parcel Tax�Number(s) <br /> System Tank Only Existing System 014 �J40 t1l 4(00 <br /> B) 0 A Sanitary Permit was previously issued Permit Number Date Issued <br /> IV.Type of POWT System:(Check all that apply) <br /> PQ Non-pressurized In-ground 0 Mound 0 Sand Filter 0 Constructed Wetland <br /> 0 Pressurized In-ground 0 Holding Tank 0 Single Pass 0 Drip Line <br /> 0 At-grade 0 Aerobic Treatment Unit 0 Recirculating 0 other: <br /> V.DispersalfIrreatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application p 'tion Rate 6.System Elevation 7.Final Grade <br /> Rate(GalsJday/sq.fl '�4 <br /> Required Proposed i7lion.1h) <br /> evation <br /> 300 L0,17 43�, 1� vi?, �z <br /> V1.Tank Ca ity in tal #of Manufacturer Prefab site Steel Fiber- Plastic <br /> Information Gs Ilons Gi�aolllons Tanks Con- Con- glass <br /> New Existing Crete structed <br /> Tanks Tanksg <br /> e-% -LA 0 0 0 1:1 01 <br /> 0 13 11 0 <br /> 1 M . 0 <br /> V11.Responsibility Statement <br /> 1,the undersigned,assume respon ibility for installation of the POWTS shown on the attached plans. <br /> Plumbers Name(print) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> ulae 91(.6.401 1 AA�_� 1 .7 1/ 3 419—Z4 Ir <br /> Plurtbees Address(Strect,City,State,Zip Code) I/ <br /> XO A- �/ '�,/�'- e-- J �7'2 <br /> VH1.County/Department Use Only A <br /> 13 Disapproved Sanitary 1`7�;im(Includes Groundwater Date Issued I ps) <br /> 0 Owner Given Initial Adverse ' Surcharge /v), <br /> Determination <br /> JX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07100 <br />