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7completed <br /> Buildings Division <br /> Sanitary Permit Application .Washington Ave. <br /> In accord with Comm 83.21,Wis.Adm. Code PO Box 7302 <br /> See reverse side for instructions for completing this application on,WI 53707-7302 <br /> Viseonsin Personal information you provide may be used for secondary purposes (Suorm to county if not <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] <br /> state owned. <br /> Attach complete plans to the county copy only)for the system,ona er not less than 8-1/2 x 11 inches in size. <br /> County State Saitary Permit Number ❑Che k if revisi n to revio a plication State Plan I.D.Number O I <br /> I.A ication Information-Please Print all Information Location: <br /> Property Location <br /> Prop"Owner Name , <br /> 1/4 1/4,S�` ,N R11 ior W <br /> izy- CamsLot Number Block Number <br /> Property Ownees Mailing Address <br /> N C92M N7!=S <br /> Phone Number Su d'vtston Name or CSM Number <br /> City,State <br /> t,Jl7tS G3S- 8748 � C.Sin V� �3s <br /> ❑city <br /> II.Type of Building: (check one) ❑Village <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms:_ ` Town of 560rr <br /> ElPublic/Commercial(describe use): ✓ <br /> ❑ State-Owned <br /> 111.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest RoadG!C'6WW15 <br /> A) L C21 ❑ Parcel Tax Number(s)�New System 2. ❑ Replacement 3. Replacement of 4. <br /> Addition to <br /> S stem Tank Only Existing System Q K 1 S <br /> Permit Number Date Issued <br /> B) <br /> ❑A Sanitary Permit was previously issued <br /> IV,Type of POWT System: (Check all that apply) ❑ Sand Filter ❑Constructed Wetland <br /> ❑Non-pressurized In-ground Vmound <br /> ❑Pressurized In-ground ❑ Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: 7.Final <br /> I.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation Elevation rade <br /> Required Proposed Rate(Gals/day/sq.ft.) (Min./inch) n <br /> AZf 1.0 �-- q •Z /00- <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Gallons Tanks Can- Con- glass <br /> Information Gallons <br /> New Existing Crete structed <br /> Tanks Tanks ❑ ❑ ❑ ❑ <br /> S loco wo <br /> ❑ ❑ Cl <br /> X00 f°Q° <br /> VII.Responsibility Statement <br /> I,the undersigned,assume res onsibili for installation of the POWTS shown on the attached fans. Business Phone Number <br /> Plumber's Name(print) Plumbers Signature(no stamps): MP/MPRS No. <br /> linumber's Address(Street,City State,Zip Co e) <br /> 2-776° 3,e W l3sr <br /> VIII.County/Department Use Only <br /> ❑Disapproved <br /> Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Ageen s) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee �6 s OJ a2 Q <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />