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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code <br /> iconsin See reverse side for instructions for completing this application 201 W.Washington Ave. <br /> Department of Commerce Personal information you provide may be used for second PO Box 7302 <br /> [Privacy Law,s. 15.04 1 m purposes Madison,WI 53707-7302 <br /> ( )( )] (Submit completed form to county if not <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. state owned.) <br /> County State Sani Permit Number <br /> Lt C�� ❑Chec if revision to previous application State Plan I.D.Number <br /> I.Application Information-Please Print all Information ID <br /> Prope neer Nan, Location: <br /> 0/1 N 7 19a A, f Av T F A�/ Property Location <br /> Property <br /> 0w/ner / <br /> s Mailing Address 1/¢f is 1/4,SZ G T c/0,N,RE(or)6W <br /> Lot Number ! / <br /> �DEU�t/V�S /� ilf Block Number <br /> City,State Zip Code <br /> lodd f y Phone Number y bdiv'sion Name orr CS Number <br /> 11 Type of B JI I` <br /> g: (check one) 3 <br /> I or 2 Family Dwelling-No.of Bedrooms: ❑City <br /> ❑Public/Commercial(describe use):_ ❑Village <br /> ❑State-Owned Town of / <br /> Nearest Ro ��11 <br /> /�l.f•i'3 <br /> III.Type of P rmit: (Check only one box on line A. Check box on line B if applicable) <br /> Parcel Tax urnbe s) <br /> A) 1. ew 2. ❑Replacement 3. ❑Replacement of <br /> System System Tank Only 5' 6. ❑Addition to <br /> B) <br /> ❑A Sanitary Permit was previously issued Permit Number Existing System <br /> AVV-Type Of POWT System:(Check all that <br /> apply) Date Issued <br /> Non-pressurized In-ground <br /> ❑Pressurized In-ground ❑Mound ❑Sand Filter <br /> E3 At-grade ❑Holding Tank ❑Constructed Weiland <br /> ❑Single Pass ❑Drip Line <br /> ❑Aerobic Treatment Unit <br /> /t vC� 3 in uy� _ ❑R9circul Ing ❑Other: <br /> V.DispersaVTreatment Area Information: 7a f0. <br /> 1.Desi Flow <br /> (gPd) 2.Dispersal Area 3.Dispersal Area <br /> Required Proposed ed 4.Soil Application 5.Percolation Rate <br /> 41j-C) p Rate(GalsJday/sq.ft.) (Min./inch) 6.System Eleva ion 7.Final Grade <br /> Ta (0 y3 (9s1 T' 9� Elevation / <br /> VII.Tank � "� 'T-4 <br /> Capacity in Total #of ManufacturerT 3 s qS 7 <br /> Information Gallons Gallons Tanks Prefab Site Steel Fiber. Plastic <br /> New Existing Con- Con- glass <br /> Tanks Tanks crete structed <br /> S��' G X �4 D d � S�d N./ ❑ ❑ ❑ ❑ <br /> X lOGb ❑ ❑ ❑ ElVIII.Responsibility Statement n <br /> 1,the undersigned,assume responsibility for installation of the POWTS shown o <br /> mber's Name(p ' t) Plumber's Signature no stamps): ched plans. <br /> cc(��4£ w�,ti-S RSBusiness Phone Number <br /> d <br /> PI ber's Address(Street,City,State,Zip C d <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee Date Issued Issuing Age t Si <br /> Determination (IQ0 stamps) <br /> X.Conditions of A �2 �0 UZ <br /> Approval/Reasons for Disapproval. ' <br /> 56D - /ds% 79 <br /> SBD-6398(R 07/00) <br /> r[ s <br />