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7� <br /> • , Sanitary Permit Application Safety&Buildings D ' i <br /> 7_ In accord with Comm 83.21,Wis,Adm. Code 201 W.Washingto/ . <br /> See reverse side for instructions for completing this application PO Bo <br /> `�SCOnSin <br /> Department of Commerce Personal information you provide may be used for secondary purposes Madison,WI 53707Q2 <br /> [Privacy Law,s. 15.04(1)(m)) (Submit completed form to coun <br /> Attach complete plans to the coon copy only)for the system,on paper-got less than 8-1/2 x I1 inches in size. state o <br /> County <br /> Tr j State Sanit a '[ '` ❑C k if rgyision to revious pplication State Plan L D.Number <br /> I.A ication Information-Please Print all Information <br /> Location: � <br /> Property Owner Name Property Location 1040,N <br /> h �/� <br /> R 1/4 1/4,S /040,N or <br /> Property Owner's ailing Address Lot Num Block Number <br /> o A la. 29i 2 <br /> City,State Zip ode Phone Number Subdivisi-dwWame or CSM Number <br /> ZI$ 'SJZ4 ADD D VV <br /> I.Type of Build' g: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> Public/Commercial(describe use): own of <br /> ❑ State-Owned •,f4(�Svw <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Py�q�j,�Twtf umber(s) <br /> System Tank Onl Existing System �/1�5—�Jas(7—3)—a <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> IV Type of POWT System: (Check all that apply) <br /> on-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 /> I.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Req <br /> Proposed� 7 ��'�Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> ¢ . 991.0 <br /> VI.Tank Capacity in Total i#of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Can- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> lom Doo l ��tq►,/ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached Tans. <br /> Plumber's Name(print) •' Plumber's Signature(no stamps): MP/MPRS No. r Business Phone Number r <br /> & 4_09 S — �J 7 <br /> Iflumber's Address(Street,City State,Zip Code) <br /> 27760 3S Wfam WI. 54893 <br /> VIII.County/Department Use Only <br /> [Deteffnination Disapproved Sanitary Permit Fe�lncludes Groundwater Date ssued Issuing. ge Signaler mps) <br /> Approved Owner Given Initial Adverse Surcharge Fee) ��yy <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07,100 <br />