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L <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> Asconsin <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.) yl <br /> Attach complete plans to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. F� <br /> CSNtat SSamPe it Number ❑Check if revision to previous application State Plan 1.D.Number <br /> o p <br /> I.Application Information-Please Print all Information Location: 1 <br /> Property/Owner Name Pro erty'17LLocation !C <br /> t/ g� ��1/4' 1/4 S T ,N,R""E o W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 02- WJCDu4 A%/- 7-- <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> .Sr PAUL I wl• 1551os- 651 09- 1q44 <br /> I Type of Building: (check one) ❑city <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑ Public/Commercial(describe use): Town of <br /> ❑ State-Owned t� <br /> III.Type of New <br /> (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. �New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System I Tank OnI5 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 /> :P9Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-prade ❑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 /> 7-s'Vdio 643 'f8 . 7 �-- ° .�, 0 ?7-5- <br /> VI. <br /> I.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 Tanks <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber s Name(print) Plumber's Signature o s ps): MP/MPRS No. Business Phone Number <br /> r afhxv #oPK'Ns + 2�S 8 51111,5- %6- 4157 <br /> Plumber's Address(Street,City,State,Zip de) <br /> VIII.County/Department Use Only <br /> 'pp ❑Disapproved Sanitary Permit Fe (Includes Groundwater Date issu Issuing A Si m ) <br /> Aroved ❑Owner Given Initial Adverse Surcharge Fee <br /> )) <br /> Determination o� <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />