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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 /> �iseonsinSee reverse side for instructions for completing this application PO Box 7302 <br /> t bepartment of Commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 Sb <br /> (Privacy Law,s. Is.04(1)(m)] (Submit completed form to county if not <br /> state owned.)�J1 <br /> Attach complete plans m the county copy only)for the systm,on paper not lkqss than 8-1/2 x I 1 inches in size. ( R <br /> CountyZ4-1 roj / /� State Sanitary P C k if 'cion tq previous app'cation State Plan I.D. u <�J 1 <br /> I.Application Information-Please Print all In o nltion Location: O <br /> PropertyOwner Name / Property Locat�io ry / <br /> O <br /> Property OWnera Mailing Address <br /> Lot Number Block Number <br /> ® / <br /> �— <br /> City,StateZip Code Phone Number Subdivision Name or CSM Number <br /> syr 6 -- <br /> II.Type of Buildin : (check one) ❑City. <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): 21-Town of <br /> ❑ State-Owned 4)OO'l el i e r <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) NearesAX0t Road <br /> A) 1. New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Only Existing System Q o? --?Sd r7 3a <br /> B) <br /> ❑A SanitaryPermit was previouslyissued Permit Number Date 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 fa:'folding 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.DispersalArea 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> 7 Required Proposed Rate(Gels./day/sq.tt.) (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 trete strutted <br /> Tanks Tanks <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumbers N (pri ) Plumbers Signature(n ): MP/MPRS No. Business Phone Number <br /> GJ A u �d�� f ��7G 9j 59-7_-2— <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Da=/01 <br /> ng A pa) <br /> roved ❑Owner Given Initial Adverse Surcharge Fee) �J� <br /> Detemtinatiort r(JlJ <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SED-6398 R07= <br /> Ars 2 zoo/ <br /> BURNS <br /> Z N NI°UNTY <br />