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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> Visconsin <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce (Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <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�$_�rbO it umber ❑ heck if ryvision to previous application State Plan I.D.Number <br /> I.Application Information-Please {Print all Information Location: v <br /> Propc Owner Name Property Location <br /> !t/ /VE1/4&z=-l/4,S 32TWN,R/;f(oryC <br /> Property Owner's Mailing Address / Lot Number Block Number <br /> 796 UcJ Lir/Fe d <br /> City,State Zip Code p Phone Number Subdivision Name or CSM Number <br /> �! /` lCJ i <br /> II.Type of Building: (check one) ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ )9Town of <br /> ❑State-Owned n%C/S <br /> Nearest Road <br /> Parcel TaxNumber(s) <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) /e4 <br /> A) 1. ❑New 2. 51 Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> $) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> IgNon-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(Galslday/sq.ft.) (Min./inch) Elevation <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 /> �•► __�/` ❑ ❑ ❑ ❑ ❑ <br /> cJre <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumvote <br /> arae(print) /f Plumber's -gnature o s s): MP/MPRS No. Business Phone Number <br /> �� e!I/1 � /1'.fGss' �S �5��2soc, <br /> Plumber's Address(Street,City,State,Zip Code <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin a rgna (No stamps) <br /> Y I Approved ❑Owner Given Initial Adverse Surcharge Fee) (Ya`o� k <br /> Determination 3 <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> 9 2003 4~ <br /> co <br /> SBD-6398(R.07/00) ZONING�NTy <br />