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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 /> V iseonsin 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 own <br /> Attach co tete plans to the county copy only)for the system,on paper not less than 8-1/2 x I 1 inches in size. <br /> County r n e State Sanitary Permit Numb Check'f visio to previous application State Plan I. <br /> I.Application Information-Please Print all Information I Location: <br /> ProRefty Owner Name A Property Location �y p (� <br /> �'lrlh'j_ �_erS OY\ i/4 v/4 S 1 /TJ N W <br /> Property Owners Mailing Address Lot Number Block Number <br /> 0 rCar Wi 4 daolrl-� � <br /> City,State /` Zip Code Phone Number Q Subdivision Name or CSM Number <br /> k 0411 ar �O �O <br /> Il.Type of Building: (check one) ❑City <br /> 0 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): 1%Town of <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nesrest Roa <br /> ✓C iii r <br /> A) 1. ❑New System 2. .Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Only Existing System — - lbt 300 <br /> B) Permit Number Date Issued <br /> 13A SanitaryPermit was viousl issued <br /> IV.Type of POWT System:(Check all that apply) <br /> ❑Non-pressurized In-ground )4mound ❑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 !tate(G&Wday/sq.R) (Min./inch) Elevation <br /> s0 t5_0 vs� sr Y S I <br /> VI.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 /> /60V <br /> (000 <br /> Gtl PE37 ❑ 11 <br /> ❑ ❑ ❑ <br /> � x a <br /> V11.Responsibility Statement <br /> I,the undersigned,assume responsibility fir installation of the VOWTS shown on the attached plans. <br /> PI mbees Namc ' t) Plum s Signaum(n s): MP/MPRS No. Business Phone Number pp// � <br /> `S 3 �� 7/� ZO <br /> lumbers Address(Street,Citf,State.Zi Code> <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Is ed Issuing Agen 1 s) <br /> proved 1 ❑Owner Given Initial Adverse Surcharge Fee) / ,ape <br /> Determination C7v <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 807/00 <br /> C v 2001 <br /> BURN TT COUNTY <br /> ZONING <br />