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Sanitary Permit Application Safety&BIDivisionsionIn accord with Comm 83.21,Wis.Adm. Code 201 W. ve.` srronSin See reverse side for instmetions for completing this application 302Department of Commerce Personal information you provide may be used for secondary purposes Madison, 302[Privacy Law,s. 15.04(1)(m)] (Submit completed form noted. <br /> Attach com lete lana to the court co onl for system,on paper MUM than 8-1/2 x 11 inches in size. U` <br /> County "1 State Sani P it umber O if ' io to previous ap ication State Plan I.D.Number <br /> /3urnp Jam- <br /> I.Application Information-Please Print hlf Information Location: <br /> Property Owner Name Property Location <br /> JeFF _ 4J 1/4 SE (orYC <br /> Property Owners Mailing Address Lot Number Block Number <br /> CunN kSScrs2eT dtf <br /> City,State Zip Code Phone Number Subdivision N e or CSM Number <br /> IV FL 13, /Yl nr,- Sb 0 5-7 SO7 (0 (03--7719' /vloand &C-(A Llss- <br /> II.Type of Building: (check one) 13 city <br /> , 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): CkTown of <br /> ❑ State-Owned -e oft d n <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) earest Road <br /> S n/'ai l'r 0 W3 �'. <br /> A) 1. ❑New System 1 2. ;Wkeplacement 1 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Only Existing System f3- 700 <br /> B) Permit Number Dale Issued <br /> El SanitaryPermit was previouslyissued <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(Galslday/sq.It.) (Min./inch) Elevation <br /> 3 6 o uaq 6A t � y9, /0/, y <br /> VI.Tank Capacity in Total p of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> Z�P�lG 7SD yS0 ❑ ❑ ❑ ❑ <br /> rN m 5 oL Sop 13 ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I the undersigned,assume responsibili for installation of the POWTS shown on the attached plans. <br /> Plumbers Name(print) Plumbers Signature(no stamps): MP/MPRS No. Business Phone Number <br /> LU„ 1?(4 �Ad lr, Iatm - 2-2 7 <br /> Plumbers Address(street,City,state,zip Code) _ <br /> o4q 70d, Grn i�/reh coy 641 �7 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater DateI ued Issuing Si s) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) 3 <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />