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Nrisconsin a'r)O 201 W. Washington Ave.,P.O.Box 7162 u n e <br /> Madison,WI 53707-7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application Salutary Permit Number \ <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> ma be used for Seca xs Privac Law,315. 1)(m) ❑ Check if Revision <br /> I. Application Information-Please Print All Information Sam Plan I.D. Number <br /> Property Owner's Name 7 <br /> Parcel Number <br /> RObrn a rens La vt-a l 0 (0 — 2335` O 3667 <br /> Property Owner's Mailing Address <br /> Property Location <br /> /0960Linwood Farwsf (fir, $W u/VW ',f:S 3SrT 4D N,R 16 <br /> City.Stade Zip Code Phone Number Lot Number Block <br /> ok Nymhor <br /> I <br /> SS3/6 763- 4(P-8�/ Subdivision Name C Number j <br /> Cha,„ ern MAI 606Cr7 <br /> H.Type of Building(check all that apply) <br /> �.1 or 2 Family Dwelling-Number of Bedrooms <br /> 3 ❑city <br /> ❑ Public/Commercial-Describe Use []village <br /> �lownahip 0Hklahat <br /> ❑Stam Owned Nearest Road <br /> O o 0 l`- Lill <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) , <br /> A. t ® New 2 ❑ Re luemem For County use <br /> p System 3 ❑ Replace= of 6 ❑ Addition m <br /> stem Tan lr Only Existing System <br /> B- ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 ❑ Non-Pressurized In-Ground 210 Mound 47❑ Said Filter 50❑ Constructed Wetland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> �7 9se17`S`'6' SO <br /> 7 AW ss� .� <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site I Steel Fiber ! Plastic <br /> Gallons Gallons of Tanks <br /> Concrete Constructed Glass <br /> New F.zisdng <br /> TI <br /> Septic <br /> TaNrs I <br /> Septic or Holding Tank /0O _ /dao <br /> Dosing Chamber bio 6ao <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRs Number Business Phone Number <br /> _ I <br /> zzsssl 15- 46- 41 <br /> Plumber's Address(Street,City,Sate,Zip Code) <br /> 2-7 7 10 o /'w & 0twi , <br /> VIII. Court /De artment Use Ofily <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing A t S' lure fN ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse � y63 <br /> Determination 7 7 <br /> LY. Conditions of Approval/Reasons for Disapproval <br /> I� <br /> i <br /> i <br /> Attach complete plana(to the C00ntr 0017)for the system on paper not lest than 81/2 x 11 laches iu size <br /> SBD-6398 (R. 05/01) <br />