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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 /> See reverse side for instructions for completing this application PO Box 7302 <br /> Via�cqnsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of commerce completed form to (� <br /> [Privacy Law,s. 15.04(1)(m)] (Submit county Ty if not ,y..I <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,osk paper not less than 8-1/2 x 11 inches in size. <br /> County V State PermitNumberC c if rev* icon revious application State Plan 1.D.Number <br /> I.Application Information-Please Print all Information I Location: <br /> Property Owner Name Property Location <br /> Cc kr 1/4 1/4,S!`_T 9'?N,RZt(or) <br /> Property Owner's Mailing Address Lot Number Block Number <br /> e/�D/ 04V r/ zef e- <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> :h� li lr � ��y ( G/z ) 9�S• �+QS 1c�a {yrs .e4�� .Sc�.' <br /> II.Type ofBuilding: (check one) ❑City <br /> IR 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ RTown of <br /> ❑ State-Owned / r0.d e. L k <br /> Nearest Ro i <br /> rk- -e kc <br /> Parcel Talc Number(s),=-, _ o S-c1l � <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. 13 New 2. )17 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(Gals !day/sq.ft.) (Min./inch) Elevation <br /> 1-7 y7/o ,$oe /e4?. 0£' le-y' <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 /> C <br /> VIII.Responsibility Statement 10 12 C-7 C lie <br /> I,the undersigned,assume responsibility for installation of the POWTS shown P on the attached plans. <br /> Plum s Name(print) Plumb Signa (n ps): MP/MPI No. Business Phone Number <br /> 0k!, r � <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issui A nt Signatu stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination , <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> AUG =S 2ow <br /> BURNETT COU <br /> NING <br /> SBD-6398(R.07/00) <br />