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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 /> Visconsin See reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> 10 <br /> Department of commerce (Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)for 1he system,on paper niq less than 8-1/2 x 1 I inches in size. <br /> CouState Sanitary it Number ❑ e if reyi-ionto previ a lication State Plan I.D.Number <br /> LF2VA <br /> I.Application Information-Please Print all Information Location: <br /> Property/]O gwnerName Alroperty Location G <br /> -/V r� N <br /> 0^) Ld1/4S4)1/4,S ).,T' 6,N,R/(or) <br /> Property Owneft Mailing Addre9V Lot Number Block Number <br /> L ke, PJ <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> e�4 fir t-) 55Y8 7 3 <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ Y[Town of <br /> ❑ State-Owned J- Js' . 2 <br /> Nearest Road AN /j <br /> 720a' <br /> Tax MI(T) _ <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) I. ew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> Dkon-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 /> '300 � 7 <br /> VII.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 /> 1 Tanks I Tanks <br /> s c fic 00 Uer4d e.56 40 ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(prin Plumber's Signature o scam s): MP/MPRS No. Business Phone Number <br /> ;77��� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> y N 6�r 5f` 'S i r,e .-t J Gf/ syr';P 2 <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee ncludes Groundwater Date Issued Issuin g Signatu stamps) <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee) app ID) <br /> Determination lJV W <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />