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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 /> Visconsin See reverse side for instructions for completing this application PO Box 1302 <br /> Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce completed[Privacy Law,s. 15.04(1)(m)] (Submit p lete <br /> d form to county if not 91 <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x 1 I inches in size. state owned.) <br /> Co un State Sanitary Permit Number ❑C c if�sion�g us application Stats Plan I.D.Number 9� <br /> 61/°.0 e 8 92 C' /vo <br /> I.Application Information-Please Print all Information Location: <br /> Prope Owner Name <br /> � Property Location <br /> l /6 <br /> 1/4 1/4,S.3- T/,N,R E(o W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> - 7f 7 eXT C�e-s f /40 e , G,L, 3 <br /> City,State Zip Code Phone Number <br /> Subdivision Name or CSM Number <br /> II.Type of Building: (check one) ❑city <br /> ;X 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ ^� ;*Towf <br /> ❑State-Owned Q/11 ;�/�j <br /> Nearest Road <br /> o-ouAjele� AOf <br /> Parcel TaxNumber(s) S S /QQ <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ew 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.T pe 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 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 97� 9 99, . <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 Tanks <br /> t �� 1-1 ❑ El <br /> 000 _— d'Dv <br /> am 60z7 `� �jBU ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(p hit) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> lumber's Address(Street,City,State,Zip Code) <br /> .BoX s/ Sim e^-) w yF 7,2 <br /> IX.County/Department Use Only 1 <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing A ignature stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) r <br /> Determination 9S',�( DAF <br /> X.Conditions of Approval/Reasons for Disapproval:9,4 l <br /> DI <br /> i s E,cpl',ejP�> a01�2q JUN - 9 20W <br /> NTS( <br /> SBD-6398(R.07/00) ZONING <br />