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Sanitary Permit Application Safety&Buildings Division <br /> Visconsin <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W Washington PO Box ve.See reverse side for instructions for completing this application <br /> Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce (Submit completed form to county if not <br /> [Privacy Law,s. 15.04(1)(m)] Qc <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Permit Number ❑Chr if revilipn tovious a lication State Plan I.D.Number <br /> 4 0� <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name r Property Location <br /> / r! N Y � AIS/ 1/4 1/4,S a5T 110,N,R/ E(or)CL <br /> Property Owner's Mailing Address It Lot Number Block Number <br /> `I7 l t J 6/a-4 S 66 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Go e Gpo U e .5-:5-0/ -d v ri <br /> II.Type of Building: (check one) ❑City <br /> 1� - 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ Dorown of <br /> ❑ State-Owned l— T'+ 4`C O <br /> Nearest Road <br /> p v e r/,,+tV el GAJ <br /> Parcel Tax Num r s <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. PWew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) ElPermit Number Date Issued <br /> A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> Dion-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 /> 3o a 4/0? 4,'3 ;2- 7 - . s' <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 /> Tanks I Tanks <br /> S C C. 00 ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(nodamps): MP/MPRS No. Business Phone Number <br /> ewAde &'P�x'1m W _ �2 76 9 y-7,28'is'o, <br /> Plum,beees Address(Street,City,State,Zip Code) <br /> Ire e"-'-j li✓ �� <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater sued Issuing gent Signature(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) 1 <br /> Determination o� <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> 4>0N/All N <br /> SBD-6398(R 07/00) <br />