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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 93.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> *Sconsin personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned. <br /> A ach 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 Sanit Perm Numbe Check if revisi n to rev us application State Plan I.D.Number <br /> reD <br /> I.Application Information-Please Print all Informa on Location: <br /> PropKy Owner Name Property Location , , <br /> 1/4 1/4, T N,Rio <br /> Property Owner's Mailing Address Lot Number Block Number <br /> D 2 fi Avd ,4rA B <br /> City,State{/l� kyr Zip Code Phon/e Number SibrImismn-Name SM Nurn e <br /> II.Type of Building: (check one) ❑City <br /> ^ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): Town of <br /> ❑ State-Owned SwXss <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest RgeldC K /-�'le30Sa <br /> A) 1. ❑New System 2. l�Replacement 3. ❑Replacement of 4. ❑Addition to Parcel ax Numberfs) <br /> S stem Tank Onl Existin S stem 3a J a <br /> y— Baa- <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> g,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 '.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.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 /> dad Iwo ❑ ❑ 11 1:1 � <br /> otJ arwHs�.'a <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) Plumber's Signature(nops): MP/MPRS No. Business Phone Number <br /> 'OpA)4d, /f,)W-4 x,2749 <br /> Plumber's Address(Street,City,State,Zip Code) jr <br /> d✓0- <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit F (Includes Groundwater Date Issued - Issum A nt Si a mps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Feelp00 <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />