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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 /> See reverse side for instructions for completing this application PO Box 7302 <br /> ArtSCOnSin <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 corn plete plans(to the county copy only)for the system,on aper not less than 8-1/2 x 11 inches in size. <br /> state owned.) <br /> County State Sanitary permit Number VCheck if revision to p ious application State Plan I.D.Number <br /> 5 733 --# �� 9B29Sg <br /> I.Application Information-Please Print all Information <br /> PropeOer eLocation: <br /> Property Loc <br /> ation <br /> O � y 700 1/4 W4,S CpL3 , ,R/E(or)Q <br /> Prope Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> rfru w <br /> II.Type of Building: check one) ❑city <br /> kL 1 or 2 Family Dwelling-No.of Bedrooms: ❑ ilxage <br /> ❑Public/Commercial(describe use):_ fown of <br /> ❑ State-Owned <br /> Nearest Rpad // <br /> Parcel Tax N er(s) �� g <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> FB) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground ofmound ❑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(Galslday/sq.R.) (Min./inch) Elevation <br /> .J �' <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 Tanks <br /> DOO dd ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> II.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name C iriii iii � Plumber's Signature ps): P/MPRS No. Business Phone Number <br /> Ike <br /> Numbers Address(Street City,Stat,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing gnature ps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) 2��'y� D� <br /> Determination c�L�/7 <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />