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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code <br /> 141201 sconsin See reverse side for instructions for completing this application W.Washington Ave. <br /> Department of commerce Personal information you provide may be used for second PO Box 7302 <br /> secondary purposes Madison,WI 53707-7302 <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not R <br /> Attach complete plans(to the county coe spy only)for thstem,on paper not less than 8-1/2 x 11 inches in size. state owned.) <br /> County State Sanitary Penn yjmbe 1] he revi�ipn tto�reevious <br /> �/Q S � pplication State Plan I.D.Number <br /> I.Application Information-Please Print all Information <br /> Property Owner Name / Location: <br /> Pro erty Location <br /> Property s Mailing Address l <br /> Lot Num�,1/4,S T yd,N,R/� or <br /> 5� <br /> City, tate ( )`� Block Number <br /> Zip Code `1 <br /> I Phone Number Subdivision Name or SM Number <br /> Grob u dr- 44✓vr_ 3--0/00 c <br /> II.Type of B din ( )��06- / QUi✓ <br /> g: (check one) <br /> 1 or 2 Family Dwelling-No.of Bedrooms: vz ❑City <br /> ❑Public/Commercial(describe use):_ ❑Village <br /> Town of <br /> ❑State-Owned 0/4 f IA,, <br /> Nearest Road <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Parcel Tax Numbers) <br /> 30 <br /> A) 1. New Z. ❑Replacement 3. ❑Replacement of 4. <br /> B System System Tank Only 5' 6. ❑Addition to <br /> ❑A Sanitary Permit was previously issued Permit Number Existing System <br /> IV.Type of POWT System:(Check all that a I Date Issued <br /> ;KNon-pressurized In-ground pp y) <br /> ❑Pressurized In-ground ❑Mound ❑Sand Filter <br /> 11Holding Tank ❑Constructed Wetland <br /> El At-grade ❑Single Pass EI Drip Line <br /> ❑Aerobic Treatment Unit 13Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area <br /> Required Pro osed 4.Soil Application 5.Percolation Rate <br /> "�6 Q p Rate(Gals./day/sq.R.) (Min./inch) ystem Elevation 7,Final Grade <br /> �3 Elevation <br /> VII.IL Tank Capacity in Total #of ' a �� " <br /> Information Gallons GalloManufacturer Prefab tens Tanks Sel Fiber- <br /> New Existing Con- Cot- <br /> Tanks Tanks crete structed <br /> loA� /1.1 o r4aes,o ° ❑ <br /> VIII.Responsibility Statement <br /> ° ° ° ❑ ❑ <br /> 1,the undersigned,assume responsibility for installation of the PO WTS shown <br /> Plumber's Name rint) Plumber's Signature stam s <br /> P) MP/MPRS on the attached plans.No. <br /> Business Phone Number <br /> Plumber's Address(Street,City1136 01Y ,State,Zip Code) ' �Y9 t 7� p/ <br /> t �l C <br /> IX.County/Department Use Only 7„2 <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Is <br /> Appved ❑Owner Given Initial Adverse Surcharge Fee)Q� ued <br /> roIssuing t Sig m fps) <br /> Determination ---tlJ ie.i� <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />