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Sanitary Permit Application Safety&Buildings L <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washingtoi. <br /> `�seonsinSee reverse side for instructions for completing this application PO Box . <br /> Department of commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7_ <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if n, <br /> state owned: <br /> A h co Tete plans to the coup co only)for the s stem n r not le than 8-1/2 x 11 inches in size. <br /> County U�,N State Sanitary N f vi to vious appli tion State Plan I.D.Number <br /> [-7 <br /> I.APPlicatiOn Information-Please Print all I formation Location: <br /> Property Owner Name <br /> t Property Location <br /> 1/4 1/4,S--/TM R/(or <br /> Property ownees Mailing Address <br /> Lot Nu her Block Number <br /> L,t�, <br /> '00U 4!!F7 c7G,L <br /> City,State Zip Code Phoue Number SubdivisionName or CSM Number <br /> .t� 76 <br /> II.Type of Building: (check one) ❑City <br /> ❑ I or 2 Family Dwelling-No.of Bedrooms: �' ❑Village <br /> ❑ Public/Commercial(describe use): gTown of <br /> ❑ State-Owned <br /> Q 14h,1J' <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road 2 7:2 p <br /> ir1 i SQti1 <br /> A) 1. ❑New System 2. OReplacement 1 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Only Existing System o;2 p 7V p <br /> B) Permit Number Date Issued <br /> 11A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System:(Check all that apply) <br /> ❑Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground AW-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(GalsJday/sq.fl) (Min./inch) Elevation <br /> 3 00 -- — I <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 /> NO Gov .0 ,qcJ ° ° ° ° <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> 1,the undersi ed,assume res ibili for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) P t is Signature no stamps); MP �. Business Phone Number <br /> g t4 <br /> 79J;7—72 <br /> Plumber's AddrossCity,State,Zip Code) ,96 <br /> a Sl iii G.J W S <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary PermI ru Grounder Date Issu Issuing <br /> Determination Si tt pa) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) ('7� <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07100 <br />