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a 56 41195'016 <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> Visconsin Personal informationou provide may be used for second purposes Madison,WI 53707-7302 <br /> Department of Commerce [privacy Law,s. 15.04(1)(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 /> County State SanitaPem.t b{p ber [Ih k if revision to previos ap lication State Plan I.D.Number <br /> r n <br /> G. ti Com!( {7� <br /> I.Application Information-Please Print a 1 Information Location: <br /> Property Owner Name Property Location <br /> 1 Hl S NIV1/4IVIr1/4 S3A T 446,N,WE or <br /> Property Owner's MailingAddressLot umber (Block Number <br /> 111 J <br /> W- eavtr S7 A f / !� Je C'S�J S <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> vdn*N W�( I54to 1 -2lS 06 171 CSh-, =rkc�- Vla P3D <br /> 11.Type of Building: (check one) ❑City <br /> �L 1 or 2 Family Dwelling-No.of Bedrooms: 2— ❑Village <br /> ❑ Public/Commercial(describe use): 0 Town of <br /> ❑ State-Owned p It land <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nea st Road <br /> A) 1. at New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numbers) <br /> System Tank Only Existing System —Q D <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 S.Percolation Rate 6.System Elevation 7.Final Grade <br /> 3 O 0 Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 'If JA 8 Ore . 7 �� . �' q69. 6 <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks / <br /> goo S/�a h, 91 ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) P1 ber's Signature( o sta s): MP/MPRS No. Business Phone Number <br /> R1G4,f&-d 7 <br /> Plumber's Address(Street,City,State,Zip C de) <br /> 776 D (Y"-), '35— Wed ,- r�r Qg <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee fkncludes Groundwater Date Issued Issuing Zen ignOU <br /> Mps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) /b <br /> Determination �J <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />