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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 /> See reverse side for instructions for completing this application PO Box 7302 <br /> Visconsin 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 forth to county if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper of less than 8-1/2 x 11 inches in size. <br /> County, ,S State Sanitary Perm t Number ❑ eck if rc*ion to�revious lication State Plan 1.D.Number <br /> y/ of e 4353 (4, a, <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> P t�— tole— S 1/4 1/4,S ;;I'TJp,N,R/E(or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 3Y.30 5 ?' &w,Y 70 &,L, z <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> e,,,,Ie <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> Public/Commercial(describe use):_ $=Fown of�_.. <br /> ❑State-Owned '/ e// <br /> NearpstRoad 7� <br /> Wge <br /> Par 1 r s <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) L w 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> $) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> Pl�`lon-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 /> I y3 �Y17 <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 I Tanks <br /> S L rC 00� dUd f�4/ )ff�' ❑ ❑ ❑ ❑ <br /> ❑ 11 ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(p int) Plumber's Signature stamps : MP/MPRS No. Business Phone Number <br /> w�e K 41^ Gr/0.4nl— "-�.;z';;�5/ F>/' 7;' g' <br /> Plumber's Address(Street,City,State,Zip Code) lor <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin ign stamps) <br /> &'A roved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> hep v <br /> �o�c <br /> SBD-6398(R.07/00) N� <br />