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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> VisconsinSee reverse side for instructions for completing this application PO Box 7302 <br /> Department of commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> Attach Complete plans to the county copy only)for the system,on papernot less than 8-1/2 x I I inches in size. state owned. <br /> County//�� State Sanitary Permit Number ❑ heck if vision to revio application State Plan I.D.Number <br /> 80.rK EYf1. 4 <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location _ <br /> C( uL aL c.'Sdfi 3W 1/4 NW 1/a Sd-0 TW ,N,R/6E or <br /> Property Owner's Mailing Addresss Lot Number Block Number <br /> 7768 L Rd. U �, <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Dor%b+wr W1 5-4930 -Its— 1016 —7/47 <fdm v,l 11 p 1 /07 <br /> II.Type of Building: (check one) ❑City e 01 U/�r'c� l/21117 u� <br /> a 1 or 2 Family Dwelling-No.of Bedrooms:� _ ❑Village 9 y <br /> ❑ Public/Commercial(describe use): 0 Town of AA <br /> ❑ State-Owned 0)%k- G� <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road pp <br /> A) 1. O New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numbers <br /> System Tank OnlyExistingSystem 0}.4-Q( 7 Od '7d 0' <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System: (Check all that apply) <br /> ERNon-pressurizedIn-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 /> L Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Applicaan5.:P :(:, on Rate 6.System Elevation 7.Final Grade <br /> /,6-..0, Required Proposed Rate(Gals./daElevation <br /> 7Sa o g0�0 , ss-- <br /> VI.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 /> 968 96 <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) Plumber's Signa=nos MP/MPRS No. TBusinessPhone Numberfitcl, w / 22S'$S/ 9`66- qls�? <br /> Plumber's Address(Sheet,City,State,Zip de) <br /> I-Z760 H-t3-� if eh_<ll w.L S�g5 3 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued - Issuing Ag t i re s) <br /> A oved ❑Owner Given Initial Adverse Surcharge Fee) 'w, Z� <br /> Determination c `� <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />