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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 /> PO Box 7302 <br /> VLCOMSI-n See reverse side for instructions for completing this application Madison,WI 53707-7302 <br /> Personal information you provide may be used for secondary purposes (Submit completed form to county if not <br /> Department of Commerce [Privacy Law,s. 15.04 1 (m)] <br /> [ Y O 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. <br /> Count State Sanitary Permit Number ❑Check if revision to previous ap lication State Plan I.D.Nuipber <br /> I.Alication Information-Please Print all Information Location: <br /> Property Owner Name Property Location �/ <br /> Tv, <br /> p-A -0 1/4 1/4 S 1 T40 ,N RAE or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 5 11 k Rte I <br /> City,State Zip Code Phone Number Subdivision liare or CSM Number <br /> II.Type of u lding: (check one) ❑City S <br /> ❑Village <br /> ❑` 1 or 2 Family Dwelling-No.of Bedrooms: Town of 44 <br /> % Public/Commercial(describe use): 2 5 �12 TORN scvr <br /> ❑ State-Owned 414, <br /> I1I.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road V Il-1 Agog gWo <br /> l <br /> A) 1. *ew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Pay el,'1'q Nuri o. Qa 300 <br /> S stem Tank OnlyExistingS stem lJ po(fY3 rrJJjj ff <br /> B) Permit Number Date Issued 1 <br /> ❑A Sanitary Permit was previously issued <br /> I .Type of POWT System:(Check all that apply) &00 <br /> Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass El 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 F667-S <br /> System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 1590 LI A 4F Z J AA - $ 0:3 o.s <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 /> ❑ ❑ ❑ ❑ <br /> a 2 4*Aa <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersi ed,assume res on ibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(nos mps): MP/MPRS No. Business Phone Number <br /> c�fA2n pwk-ts ZZS$S1 l�- <br /> Iumbees Address(Street,City,State,Zip de) <br /> "77&0 Avz 35' WeasI1=.2 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Pe Fee(Includes Groundwater Date Issued Issuing g igna mps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fe / J'� <br /> ,,`` Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />