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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 /> 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. S <br /> County State Sanitary Permit Number ❑Chec 'f revision to previous ap ication State Plan 1.D.Number <br /> 45go cr a <br /> I.Application Information-Please Print all Information Location: r <br /> Property//(Tuner Name Property Location <br /> ��►1 h Lj �'/ 1/4 1/4,S24C TJY,N,1171(or <br /> Property Owner's Mailing Address Lot Number Block Nujr <br /> 2 / S0.A� f e Tr <br /> 10 3 Gov �. Ct a <br /> City,State/ Zip Code Phone Number Subdivision Name or CSM Number <br /> /�'�a M ! �l /-f ( -7.5' C57,Fl Yo/z Axre ZZS <br /> II.Type of Building: (check one) ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: z— ❑Village <br /> ❑Public/Commercial(describe use):_ i$Town of <br /> ❑ State-Owned Lq <br /> N est Road <br /> c279 S 4e-le- <br /> Parcel <br /> Parcel Tax Number(s)Q2- <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. ITRcplaccment 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 ❑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 Rats(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 300 '." <?Z. 6 1 .5- 1 �S So 9 7, 6 f/ <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 /> �C 'jSo � 4� 'e'Sef ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of a POWTS shown on the attached plans. <br /> Plum arae(print) Plumb s igna ( ): MP/MPRS No. Business Phone Number <br /> e �� <br /> PI ber's Address(Woet,City,State,Zip C e <br /> a?z A15,1,-14 /rider. w-� SY cr'? <br /> IX.County/Department Use Only <br /> 1-57 <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued ssuing Signam o stamps) <br /> IX/Approved 1 ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> c5 , <br /> A� <br /> eUR G� <br /> Io co G %, <br /> SBD-6398(R.07/00) <br />