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44 3s8aif- ffC 20.E ' <br /> Sanitary Permit Application uildin s ion <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washin ve. <br /> `�SC0I115rin See reverse side for instructions for completing this application PO 02 <br /> Personal information you provide may be used far secondary purposes Madison,WI 53702 <br /> Department of Commerce ry p Submit completed[Privacy Law,s. 15.04(I)(m)] ( p eted form to coun rf not <br /> state <br /> Attach complete plans fro the county copy only)for the system,on paper not less than 8-1/2 x I I inches in size. <br /> County State Sinitary P Nu er eck if revision to previous application State Plan 1.D.Number <br /> I.AppTication Information-Please P 'nt all Infor tion Location: <br /> Property Owner Name Property Location ./Q <br /> _�5 Sofw 1/4 1/4,S/--()T ,N,R�E o W <br /> Property Owner's Mailing Address Lot Number Block Numb <br /> lr 4�o L1DEftl r_ D12- y <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> '✓ ) J <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 4' ❑Village <br /> ❑ Public/Commercial(describe use): own of <br /> ❑ State-Owned <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 Parcel Tax Numb s <br /> System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued E] <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 /> 1.Design Flow(gpd) 2.Dispersal A�-o r�epa 3.Dispersal Area <br /> .y 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required $SProposed SZ,Z Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 336 6aswk <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 /> L SV IW tfs ❑ ❑ ❑ ❑ <br /> c 000pwet ;60 ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumbees Name(print) PlumberIvI /MPRS No. <br /> 's Signature(no stamps): PBusiness Phone Number <br /> tNgr2p ,✓ - ?2 -957 <br /> umbee's Address(Street,City State,Zip Code) <br /> Z-77(0 3S W'5a W►. _54s93 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date sued Issuing Agent Signatu (N ps) <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee) (J �/ <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: // L- Lj <br /> r <br /> �- <br /> t <br /> SBD-6398 R07/00 r <br /> v �'l:7 <br />