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Safe &Buildings <br /> Sanitary Permit Application Safety g <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Was ' to ve <br /> See reverse side for instructions for completing this application 730: <br /> • <br /> ViscohSin personal information you provide may be used for secondary purposes Madison,WI -730: <br /> Department of Commerce Submit completed 'f <br /> [Privacy Law,s. (5.04(1)(m)] ( leted form to c no p <br /> state ed. <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. WANOR <br /> County State Sanitary P it uMber ❑Check'f rev's*o to previous a licati State Pian I.D.Number <br /> 54J2 CM <br /> I.App <br /> ication Information-Please Print a 1 Information Location: <br /> Property Owner Name Property Location // <br /> 1/4 1'1/1/4,S ZT N R16E or <br /> PropertyOwner's Mailing Address Lot Number Block Number <br /> qqq5 (roRpgsr <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> RnILI-� A'lIJ � <br /> II.Type of Building: (check one) ❑City <br /> I or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> Public/Commercial(describe use): H'rown of/'-, G <br /> ❑ State-Owned .,A' <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) I. New System 2. A Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tak Number(s) <br /> System I Tf�k�umber <br /> ExistingSystem 2 X <br /> B) Date Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System: (Check all that apply) <br /> oNon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At- de ❑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(GalsJday/sq.ft.) (Min./inch) Elevation <br /> 4-50643 648 . ? �-- ��5 Ito. S <br /> VI.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 /> L /M0 / ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) I Plumbers Signature(no stamps): MP/MPRS No. r Business <br /> Phone Number r <br /> Plumber's Address(Street,City State,Zip Co e) <br /> 277(00 3S 4J£gST�JZ lull• S4$g3 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Perini[Fe (Includes Groundwater Date I sue - Issuin ent stamps) <br /> oved ❑Owner Given Initial Adverse Surcharge Fee)` <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />