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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 /> `viseonsinSee reverse side for instructions for completing this application PO Box 7302 <br /> Department of commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> [Privacy Law,s. 15.04(l)(m)) (Submit completed form to county if not (�lJ <br /> ed. � <br /> Attach con Tete laws to the coup co only)forth system,on paper not less than 8-1/2 x 11 inches in size. <br /> state own <br /> CountyState Sani i N ❑ if revj4ioty to revio pplimtion State Plan 1.D.Number <br /> 6c.rn 4t— <br /> I.Application Information-Please Print all Into m tion Location: <br /> Property Owner Name <br /> Property Location <br /> M / 14t d <br /> Property Owners Mailing Address Lot Nu NEI/4 S 3 Tj9 N R E or <br /> Lot Number Block Number <br /> (07 Cann-(r <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> We6strP- wi .S`-fit?,-5 6146- you s-s- <br /> II.Type of Building: (check one) ❑city <br /> lid I or 2 Family Dwelling-No.of Bedrooms:�_- ❑Village <br /> ® Public/Geavnewial(describe use): Qf Town of <br /> ❑ State-Owned meer ) <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> C°nri-tr.5 r•c/ /lo� <br /> A) 1. [$New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to el Tax33-0.0. <br /> 3Nuumber(s)' <br /> 5 stem Tank O11M Inl Existin S tem c L'; <br /> 1,00 <br /> B) Permit Number Date Issued <br /> El SanitaryPermit was previouslyissued <br /> IV.Type of POWT System:(Check all that apply) <br /> Ut 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.Dis ersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 1 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> O Required Proposed Rate(Gals./da /sq.R) (Mir./inc Elevation <br /> 600 600 i� yr.Y qs� 9z9 976 <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 /> 5 es fie /6610 Arweso ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> 1,the undersigned,assume res nsibili for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature; stamps): MP/MPRS No. Business Phone Number <br /> bvU fd RaL(s A0611 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 4' 3 C 5'/i^ rrJ 6✓ ��2 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit A'960' <br /> (Includes Groundwater Date ued Issuing Si ) <br /> #rApproved <br /> 13 Owner Given Initial Adverse Surcharge Fee) /� <br /> Determination p2V0 (Y) 6 L <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />