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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 /> isconsin 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 DQ <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper Nt less than 8-1/2 x 11 inches in size. <br /> County State Sani Permit Number ❑Che if rev' ion to revious plication State P I.D Number <br /> go,s,„e c7qn <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name 1/ Property Location <br /> �>�' �' Jett T/� Sit/t/4 SH,✓/4,S "� ,�, ,riRx(or <br /> Property Owner's Mailing AdOress Lot Number Block Number <br /> Ire a/ st" / <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Il.Type of Building: (check one) ❑city <br /> 1Q 1 or 2 Family Dwelling-No.of Bedrooms: Z ❑Village <br /> ❑Public/Commercial(describe use):_ Ewtown off <br /> ❑State-Owned Tftxd� <br /> , <br /> CS <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Parcel TaxNumber(s)� 1-53 <br /> A) 1. ❑New 2. IR 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 /> ❑Non-pressurized In-ground 19 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 Crede <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> Tin ��Oh �Oa �• S `/4- C>3 /:no '6,x <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 /> x' 75c� c� t�s�r ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber s Name(print)) Plumb"' Signatur (n pps): MP/MPRS No. Business Phone Number <br /> D r �u-a o✓t vG /� <br /> Plumbers Address(Street,City,State,Zip Code) _�i�e 46 C- <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued j I ature(No stamps) <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination �y <br /> X.Conditions of Approval/Reasons for Disapproval: OCT 2 . <br /> 0 <br /> 03 <br /> e�rrtRNE <br /> ZON COUNTY <br /> SBD-6398(R 07/00) <br />