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Safet=Buildings ivision County��201 W.W .O.Box 7162iseonsln Mad7162 Sanitary Pe�r�m/it�Number(to be filled in by Co`r It ? <br /> Department of Commerce <br /> No <br /> State Plan I.D.Number <br /> Sanitary Permit Application p� (eg 5 3 <br /> In accord with Comm 83.2 1,Wis,Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl5.04(1)(m) Project Address(if different than mailing address) <br /> LR <br /> L Application Information-Please Print All Information # S ;)3 /378' S- W A 11) <br /> ! tc.s T <br /> Propen Owner's Name ck Parcel# Lot M Bla4 <br /> t�v i s n o - as-Ag-01-GQ <br /> Property Owner's Mailing Address Property Location <br /> y� /`s� S • ftp ! 11���'t-� /vsrV '/.,1�✓ZLI'/., Section <br /> City,State <br /> Zip Code Phone Number <br /> a "O7 r [i �•VQ q. <br /> TNI_V W r 7/1- <br /> 10 <br /> Ecle W <br /> IL Type of Building(check all that apply) <br /> Subdivision Name CSM Number <br /> Al or 2 Family Dwelling-Number of Bedrooms <br /> ❑Public/Commercial-Describe Use ,�7 <br /> Ali '.�State Owned-Describe Use ❑City_❑Village}Township of(,e1C.d Ft <br /> EEPerrmit <br /> mit: (Check only one box on line A. Complete line B if applicable) <br /> tem Ia Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Oth'er Modification to Existing System <br /> enewal ❑ Permit Revision ❑Change of ❑Permit Transfer to NewList Previous Permit Number and Date Issued <br /> iration Plumber Owner <br /> . WTS System: (Check all that apply) <br /> I~ <2 ❑ Single Pass Sand Filter <br /> 1 Li Non-Pressurized In-Ground ❑ Mound>24 in,of suitable soil ❑ Mound 4 in.of suitable soil �At-Grade <br /> Constructed Wetland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> I Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> S .S- 96 f, gra �y9 <br /> Ilr VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Sepuc .Holding Tank OL e a; x <br /> Aerobic Treatment Unit <br /> INC <br /> sing Che r - / 6 <br /> It7I.Responsibility Statement- I,the un ersigned,assume responsibility for installation of the POINTS shown on the at plans. <br /> Plu bis Name(Print) Plu tier's Signa[,re MP/MPRS Number Business Phone Number " I <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 <br /> VIII.County/Department Use Ortiz <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuing nt gnatur o Stamps) <br /> .Approved ❑ Disapproved //� p r <br /> Surcharge Fee) ���p �� lj 6V 64 <br /> 11 Owner Given Reason for Denial (/(� T .--� <br /> r -IX.-Conditions of ApprovaUReasons for Disapproval <br /> I <br /> I <br /> OCT 1 8 2004 I <br /> AUocb complete plans(to the Courtly only)for the system on paper not less thea d <br /> TT CO <br /> ZONING uN�Y <br /> SBD-6398 (R. 01/03) <br />