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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 /> See reverse side for instructions for completing this application PO Box 7302 <br /> Visconsin Personal information you provide may be used for secondary Madison,WI 53707-7302 <br /> Department of Commerce [privacy Law,s. 15.04(lxm)] ry (Submit completed form to county if not <br /> state owned. <br /> Attach complete plans to the county copy only)for the system,on paper no less than 8-1/2 x I 1 inches in size. <br /> County State Sanitary Permit N r El hec evisignaprevio sap lication State Plan I.D.Number fil/1 <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> JCr &C,taI NWI/49W 1/4,Sdy TNO N RIhE or® <br /> Property Owner's Mailing Address Lot Number Block Number <br /> )-753`l cJz°79Ker1:-5 94 J. <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> W,43s tet- wi s�fSr3 7<f' � , 9716 4sM 3s-a9 V., 17 EM�,c <br /> II.Type of Building: (check one) ❑City <br /> N I or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): 9 Town of O ---� <br /> ❑ State-Owned 0pk-/pn�C <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> D eu ds t/l. RX. <br /> A) 1. PrNew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Existing System 0 0-113a-7—OS-8(0 <br /> B) Permit Number Date Issued <br /> 11A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> JMLNon-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 /> 1.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 /> 11,5-0 17M 9%400 .S'_ ao g7. 00 <br /> VI.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 <br /> ic, 9b>s �/6� Sew >� ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.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 mps): MP/MPRS No. Business Phone Number <br /> Alck1ct,'C9 /�a /crus ZS gS/ °yrS=866 -q/s 7 <br /> Plumber's Address(Street,City,State,Zip ode) <br /> �?>dD #0- 3S` GIl�6stY� Lvr SS'�13 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Vce(Includes Groundwater Date Issued Issuingmtsir ps) <br /> #Al,p roved ❑Owner Given Initial Adverse Surcharge Fee) <br /> " Determination ��' 6_6 Q <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />