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Sanitary Permit Application Safety&Buildings r <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washins to v <br /> Visconsin See reverse side for instructions for completing this application PO Bo <br /> Department or commerce Personal information you provide may be used for secondary purposes Madison,WI 537 - <br /> [Privacy Law,s. 15.04(I)(m)] (Submit completed form to count/I <br /> state o <br /> Attach complete plans to the countyco only)f e system,on paper t less than 8-1/2 x 11 inches in size. <br /> County State Sanit j e 0 er C eck if f9visi d is a plication State Plan L D.Number <br /> I.Apliffication Information-Please Print all Information Location: <br /> Property Owner Name Property Location ,( <br /> As'I'`� 1/4 1/4,SOT ,N, o W <br /> Property Owner's Mailing Address <br /> Lou ber � <br /> A4-­47If q 5'�t l2l£S R�_ ,S ler2 c _� <br /> City,State1 * Code Phone Number Subdivision Name or CSM Number <br /> 48 7(S $66- 3& V 16 4go <br /> II. ype of Building: (check one) ❑City <br /> I or 2 Family Dwelling-No.of Bedrooms: Z— ❑Village <br /> ❑ Publ1C/Commercial(describe use): own of �VN <br /> ❑ State-Owned V <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road nig <br /> A) I. New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel T Numbe s) /`� <br /> System I Tank Only Existing System 44k_1 ox <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously ssued <br /> IV.Type of POWT System: (Check all that apply) <br /> ,N6on-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 Area2Tj!S77Slation Rate 6.S tem Elevation FiFinal Grade <br /> Required Proposed ch) .9 vati <br /> 90-0 ct 3 Z �-' <br /> VI.Tank Capacity in Total #of Manufacturer Prefab SiteSteel Fiber- P astic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing Crete structed <br /> Tanks Tanks <br /> (Ood IodO — ❑ Cl ❑ ❑ <br /> ❑ ❑ Cl ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume res onsibili for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> umber's Address(Street,City State,Zip Co e) <br /> 277(00 �jS (nJE85iE'K WI. 54$93 <br /> VIII. County/Department Use Only <br /> ❑Disapproved Sanitary Permit F (Includes Groundwater Date sued Issuing Ag t Si r ) <br /> 'Approved ❑Owner Given Initial Adverse Surcharge Fee),JW <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />