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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 /> NVISYpiarstmenteonsin See reverse side for instructions for completing this application PO Box 7302 <br /> of Commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed fort to county if riot <br /> Attach complete fans to the coon co only)for the system,on not less than 8-1/2 x l 1 inches in size. <br /> state owned. <br /> County Attach <br /> Sanitary Permit Number Check if revis' pre 'ous appli State Plan I.D.Number <br /> ue A <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> l Y <br /> Property O e-ha Mailing Addreae r z SE114 SW V4 S 36T /,N,RI E or <br /> / ) Lot Number Block Number <br /> 7J t ThDlnn I e. A'k LDf .rte <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 51. Pout m . ssra�� �,(. l� 3t <br /> II.Type of Building: (check one) ❑City <br /> ML 1 or 2 Family Dwelling-No.of Bedrooms:�_ ❑Village <br /> ❑ Public/Commercial(describe use): 0 Town of <br /> ❑ State-Owned w ISS <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. ❑New System 1 2. LKReplacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Only Existing System 0110 0 O/ MO <br /> B) El Permit Number Date Issued <br /> A Soni Permit 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 ❑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 Arca 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> '3040 Required Proposed Rate(GalsJday/sq.R) (Min./inch) Elevation <br /> z1v9 e13,A, 1 .7 414r d y7,3 <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 /> 000 OGD 1 NormPfG(y ❑ ❑ ❑ ❑ '�' <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I the undersigned,assume resoonsibility for installation of the POWTS shown on the attached plans. <br /> Plumbers Name(print) Plumbers Signature(no ): MP/MPRS No. Business Phone Number <br /> Wabe 3t��shdlm �i 34t9_ 77f.r6 <br /> Plumbers Address(Street,City,State,Zip Code) may' <br /> 7/hilt W.r ✓ Y 1�7� <br /> VIII.County/Department Use Only 17 10 <br /> ❑Disapproved Sanitary Permit ce(Includes Groundwater Date I sued Issuing i <br /> pproved ❑Owner Given Initial Adverse Surcharge F� �r Ob <br /> Determination t7 <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07M <br />