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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> PO Box 7302 <br /> See reverse side for instructions for completing this application Madison,WI 53707-7302 <br /> Viconsin Personal information you provide may be used for secondary purposes (Submit com leted form to coon if not <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] p county <br /> state owned.) <br /> Attach complete plans(to the county copy only)for a system,on paper not less than 8-1/2 x 11 inches in size. <br /> Coon State Sanitary Permit Number ❑97h k if r ision to previou pplication State Plan 1.D.Number O 5 Z <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name / Property Location i <br /> 61 e `'e T 1/4 1/4,S 7 T yG,N,R /E(or)(@ <br /> Property Owner's Mailing Address Lot 1 u )e; 3 Block Number <br /> ! y 33 sj` s <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> r97<�� m ,� 5V-?61- 6 <br /> II.Type of Building: (check one) ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: 13 Village <br /> 9F7'own of <br /> ❑Public/Commercial(describe use):_ <br /> ❑ State-Owned <br /> Nearest RR ad L/l <br /> �CSa <br /> Parcel Tax Numb r ) 0 3aCJ <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <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-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(Gats./day/sq.ft.) (Min./inch) Elevation <br /> VII.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 /> 7s-20 <br /> Sod ❑ ❑ ❑ ❑ <br /> II.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 stamps): MP/MPRS No. Business Phone Number <br /> A-41e )Fv ga/,�, GJa.� 2 z7eS Irl �f°y X28 6 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> r <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Signature stamps) <br /> l9'Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination 3 Gd 27 � 6� <br /> X.Conditions of Approval/Reasons for Disapproval: ,� t9 4cv-o4 <br /> SBD-6398(R.07/00) <br />