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1 <br /> Sanitary Permit Application Safety&Buildings Division <br /> V45consin <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 /> Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce t <br /> l <br /> it(Submcompleted form to county if not <br /> [Privacy Law,s. 15.04(I)(m)] state owned. <br /> Attch complete plans to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> Cou y S to Sanitary Pe it Numb r ❑ heck if revision to previous application State PI I.D.Number <br /> t - ' 8 <br /> I.Application Information-Please Print all Informatio Location: <br /> Propert Owner Name ( Property Location �/,� U <br /> cs- 47 /,- 1"/� 'L' /'`J I/4 1/4,S� T/Li,N,R/E or <br /> Property Owner's^tailing Address Lot Number Block Number <br /> 80,tom S3 / <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 1/0 e- Q r_ " s 5��ySS�s kz 9�-f IC7,91 <br /> II.Type of Bu ilding: (check one) ❑City <br /> 0,',1 or Faml':y Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): (Town of 7� <br /> ❑ State-Owned SC e / <br /> III.`rype of Permit: (Check only one box on line A. Check box on line B if applicable) Ne <br /> aCrest�Roadn <br /> A) 1. %Jew System 2. ❑Replacement 3. ❑Replacement of 4, ❑Addition to Parcel Tax Number(s) �y <br /> _ S stem Tank Only Existing System v 1q '06 <br /> B) Permit Number Date Issued <br /> ❑�,Samta Permit was previouslyissued <br /> IV.Type of P/)WT System:(Check all that apply) <br /> ❑Non-pi essuri:,A In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressor ized Ir ground Molding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dis ersaLrl reatment Area Information: <br /> 1.Design i low(gi d) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6:System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> VI.Tani Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> �- ! ❑ ❑ ❑ ❑ <br /> ej <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Res ponsif riIity Statement <br /> I,the undersigned assume responsibility for installation of the POWTS shown on the attachedplans. <br /> Plumber's Name(,print) Plumber's Signature(n ps): MP/MPRS No. Business Phone Number <br /> ZVA-t � �"d e' .�� _,2 <br /> Plumber's nddres! (Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> / i ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent Signature(No tamps) <br /> Appro\ed ❑Owner Given Initial Adverse Surcharge Fee) /� <br /> v Determination $ /'7-5-. OV <br /> IX. Condition< of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />