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/l6604 J 0L4-I� (E 9:d0 AA1 <br /> 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 Oe system,on page not less than 8-1/2 x 11 inches in size. DO <br /> County State Sari Permit Number ❑ k if revision t previo application State Plan I.D.Number <br /> N /�N Q � 45&9)`) � ,257oo <br /> I.Application Information-Please Print all Information Location: <br /> Prope <br /> rty Omer Name Property Location <br /> 401 14N ekQ 6"11A 5'4A/4,S.20T Yd N,R/ (o7 <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdi*vaien+}ame or CSM Number <br /> ll%0 s lj�;!A), S--45"o33 oi(/ ) y�7- BSJz y /� � 96 -� 9-7 <br /> II.Type uilding: (check one) 11City V I ( ( ou) t <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: 13 Village <br /> l <br /> ❑Public/Commercial(describe use):_ r� ;&Town of <br /> ❑State-Owned Q A--/H i / <br /> Nearest Road <br /> A,frK— S-,/- <br /> Parcel Tax Number s)Or y 30 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. w 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) 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 Odound ❑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 Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 41-45-o iso 1Y:5;-C> , 5-- 1� p�, y <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 I Tanks <br /> c IdeDOoe) ❑ ❑ ❑ ❑ <br /> 60c ❑ ❑ ❑ ❑ <br /> III.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name riot) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Bd I-/Y S.�-&- -0 �✓ syrr7� <br /> IX.County/Department Use Only <br /> --// ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin nt Signatu o stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination #; C) <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> It <br /> f <br /> SBD-6398(R.07/00) <br /> 0 inis system is to oe consttuctea anu iocawu in acuuruaucc wrur urc cuuubcu aPPruvcu vxw b auu wlu Mc -----_�� <br />