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Sanitary Permit Application Safety&Buildings D' ion <br /> S In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washingt e. <br /> See reverse side for instructions for completing this application PO Box 2 <br /> iseons�n Personal information you provide may be used for secondary purposes Madison,WI 537 7 02 <br /> Department of Commerce (privacy Law,s. 15.04(1)(m)] (Submit completed form to cou of <br /> state d. <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. yj <br /> County State Sanit Pe it Number ❑C ec if revis'on to previous application State Plan I.D Number <br /> 7 — 0257 8 3 ' v <br /> I.AppTication Information-Please Print all Information Location: <br /> Property Owner Name ••'' Proper !'[/yo/cation <br /> Vj <br /> n 1//'4/V 1/4,S-776 T N,N o <br /> Property Owner's Mailing Address Lot Number Block Number <br /> xOO P woop AV. c � F <br /> City,State Zip Code Phone Number Sub ' isi n N e or SM umber <br /> CWA4r__QPVVC Mtil_ Soll� �p57 n, XY Ac, <br /> II.Type of Building: (check one) ❑City <br /> X1 or 2 Family Dwelling-No.of Bedrooms: 13Village <br /> ❑ Public/Commercial(describe use): �rTown of M /onJ <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nea t Road 5. m <br /> A) 1. ❑New System 2. Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax umber(s) <br /> System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> D A SanitaryPermit 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 D 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(Galsdday/sq.R.) (Min./inch) Elevation <br /> 300 3©oj. a 100. o /0/, g oo <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 /> cSb 7 5b ❑ ❑ ❑ ❑ <br /> ❑ El ❑ D <br /> � S'�o Soo 1j_ 1-7VV <br /> VII. Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumbers Name(print) Plumber's Signature(no stamps): NIP/M. PRS No. Business Phone Number <br /> 11d4W Al ? 585/ S - 07 <br /> linumber's Address(Street,City State,Zip Co e) <br /> 2-77 0 3S W£esrE� („11. 54893 <br /> VIII.County/Department Use Only <br /> ❑DisapprovedSanitary Permit Fee(Includes Groundwater Date Issued Iss g gent Sign re(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) / a <br /> Determination [J C Q S <br /> IX. Conditions of Approval/Reasons for Disapproval: raj r f <br /> J r V <br /> �l <br /> / ©{,� <br /> SBD-6398 R01'00 <br /> BORNE �i <br /> ZoN Q_ N <br /> � Ty <br />