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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Cotrim 83.21,Wis.Adm, Code 201 W.Washington Ave. <br /> 7 <br /> Nvsevnsin Se reverse side for instructions for completing this application PO Box 7302 <br /> Person 1 information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state aimed.) <br /> Attach complete plans to the county copy only)f the system,on papetRot less than 8-1/2 x l I inches in size. <br /> County State S ' i t ber C ck'i f,revisio previou application State Plan L D.Number <br /> I. AppTication Information-Pleas;PijrWall Info oration Location: <br /> Property Owner <br /> nee�r e�rName Property Location <br /> (i —K 1/4 1/4.s7 T40 N, E or nW <br /> Property wner's Malling Address Lot Number <br /> 1031 &X4sr. -W. G.L $ <br /> Ci State Zip Co Phone Number Subdivision Name or CStit Number <br /> AWVK,P� MN I bs: v, 4 <br /> I Type of Building: (check one) ❑city <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> Public/Commercial(describe use): ;Mown 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) L ❑New System 2. Replacement 3. ❑Replacement of 4. ❑ Addition to Parcel Tax: mber(s) <br /> S stem Tank Onl Existin S stem b/ oaf — 'a� <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was previously sued <br /> IV.Type of POWT System: (Check all that apply) <br /> F <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 /> L 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(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 500 334 360 . g3 I6z•3 �� <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existi g crete structed <br /> Tanks Tank <br /> PCIPW eo x 2-700 1 ❑ ❑ ❑ <br /> c GG6 � G66 � 1 ❑ ❑ ❑ ❑ <br /> VII. Responsibility Statement <br /> I,the undersigned,assure responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plu ber's Signature(no stamps): NIP/MPRS No. Business Phone Number <br /> GEfAr?!7 L.✓ 2ZSg5� 1 715- - 07 <br /> Ai mbers Address(Street'Ci ry State,Zip Co6e) <br /> 277 3S' W5i3M W1- S4$93 <br /> VIII. County/Department Use Only <br /> ❑Disapproved SanitaryPe t Fee(Includes Groundwater Date Is wed Issuing nt Si s mps) <br /> roved ❑Owner Given Initial A verse Surcharge o2S 6 <br /> Determination <br /> IX.Conditions of Approval/Reason for Disapproval: <br /> SBD-6398 R07/00 <br />