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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 /> `�seonsin See 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(1)(m)] (Submit completed form to county if not <br /> Attach complete plans ito the coon c2a 2nl4 for the system,on paper not less than 8-1/2 x l l inches in size. state owned.. xl <br /> county State Sanitary Permit Number O Check if revision to ia�application State Plan I.D.Number <br /> rn <br /> L Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> els t✓ <br /> Property Owners Mailing Address �1/4 N"'[/4 Sf 7 TO.N ( or <br /> ^� Lot Number BI umber <br /> L""" K ]y\ ✓L e Is <br /> City,Stetg Zip Code Phone Number Subdivision Nadto or CSM Number <br /> 93 7� 1 a sm k - s.)_ <br /> II.Type of Building: (check one) ❑City. <br /> tK I or 2 Family Dwelling-No.of Bedrooms: 1)- ❑Village <br /> ❑ Public/Commercial(describe use): KTown of <br /> ❑ State-Owned '�C-I�—S1 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road t I _ / l <br /> A) 1. Qi(New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Nu ber(s <br /> S stem TankOnl ExistingSystem <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System:(Check all that apply) <br /> KNon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized in-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At- e ❑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(GalsJday/sq.R) (Min./inch) Elevation <br /> O b n X69- l r e)— ?0' O 473. 0 <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 /> JJ- Tan`k/s Tanks <br /> SQ rte. r O r ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> 1,the undersigned,assume res ibilid for installation of the POWTS shown on the attached plans. <br /> Plumber's Nam (print) Phapeessigne stamps): MP/MPRS No. Business Phone Number <br /> els W-pe a- 7/ O� <br /> Plumber's Address(Street,City,State,Zip ode) <br /> lr I <br /> VIII.County/Department Use Oifty <br /> ❑Disapproved Sanitary Permit F eludes Groundwater Date Issued Issuing en tgnatu (1't <br /> ed 13Owner Given Initial Adverse Surcharge Fee) <br /> ^A �1t J 0 <br /> Determination CAJ (� <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />