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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> `�SCO/fSinSee reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for second purposes Madison,WI 53707-7302 <br /> Department of Commerce ( )( )] pmP Submit completed county[Privacy Law,s. 15.04 1 m ( p ed form to coon 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 11 inches in size. V <br /> Coon State Sani a be ❑C c 'f revjyiont revious plication State Plan I.D.Number C <br /> / nJ j C <br /> I.Application Information-Please Print all Informatto Location: <br /> Property Owner Name Property Location <br /> ne 1 e `�/J 1/4 1/4,/s67)i'-3-1 <br /> r 5/d,N,R/�(or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> D 6 Z 7" ee7. <br /> City,State Zip Code Phone Number <br /> SfQ Subdivision-Namcor//C��SM Number <br /> X I,/ /I7 /tJ 5-/ o� ( ) c/ /7 U 7­-�' <br /> II.Type of Building: (check one) ❑City <br /> RE 1 or 2 Family Dwelling-No.of Bedrooms: -- ❑Village <br /> ❑Public/Commercial(describe use):_ $Z own of <br /> ❑State-Owned <br /> Nearest Road <br /> C O/'6�icJ <br /> Parcel Tax Number(s) -T-T- o 7 -1-c <br /> U <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> HE3 <br /> 1. ew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> 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 ;RfIIolding 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 1 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> -1700 <br /> VII.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 L <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.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 Signature(no stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit ee(Includes Groundwater Date Issued. Issuing a Sign s ps) <br /> Approved ❑Owner Given Initial Adverse Surch Fee) <br /> Determination 7 /1 Z/ <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />