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_Cxcede4 qcfu_ n' U.V4� <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> `viseonsin 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)] <br /> state owned. <br /> Attach complete plans to the county copy only)for the system,on paper not less than 8-1/2 x I I inches in size. <br /> Count S to Sanitary Permit Number ❑Ck9ck„�If 1eyigion to previous application State Plan I.D.Number <br /> 4 r-n ��� <br /> I.Application Information-Please Print all Information Location: <br /> P eriy Owner Name l� 1 f Property Location <br /> .r t1 ^�`, t'L C 1/4 l' /51/4,S 2 TX,N, (o([W: <br /> Pro ertyOwner's Mailing Address Lot Number Block Number <br /> S-S-S T) <s -10 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Ire-p- I W rl I -S-Lt -,Aq rcol/ Lo+,) <br /> II.Type of Building: (check one) ❑City <br /> W 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): fI[T<owwnd <br /> n of <br /> ❑ State-Owned <l n I <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest R <br /> tcnI- (s —70 <br /> A) 1. ❑New System 2. g Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Only Existing System ( �Z <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> >irNon-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 /> 00 SO SS 1. 2 4,3, O 9'S r <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 /> Tanks I Tanks <br /> X 75a (•tJreser' )Q ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibilij for installation of the POWTS shown on the attachedlans. <br /> Plumber's Name(p t) Plu bet's Signa ( tamps): MP/MPRS No. Business Phone Number <br /> S CS I , Zz sZ _ 7/r -_or <br /> Plumber's Address(Street,City,State,Zip Cod I <br /> �7?V�- (&t,� cd fc� los Wr` <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issui Agent Signature(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee/�S Q <br /> Determination J <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br /> OaTrayl 10 <br /> ,S <br />