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Sanitary Permit Application Safety&Buildi gs(�t�tsi <br /> ' In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Was ingioulAve. <br /> See reverse side for instructions for completing this application O302 <br /> 7302 <br /> iseonsin Personal information you provide may be used for secondary purposes Madison,Wlsatlleed.),53 <br /> Department of Commerce (Privacy Law,s. 15.04(1)(m)] (Submit completed form toonot <br /> Attach complete 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 State Sanitary Permit Number ❑Check ifrevlsl tto previ us application State Ian I.D.Number <br /> -7 CX2 <br /> I.A ication Information-Please Print all Information �� Location: <br /> Property Owner Name Property Location <br /> M►w..l=.a 1/4 1/4,S /9 <br /> T 3,N F17E oc <br /> Property Owner's Mailing Address Lotc�her Block Number <br /> 23SSo CD . RD W r6i Fr /� U) <br /> City,StateZip Code Phone Number Subdivision Name or CSM Number <br /> WR a W1 - S4$40 <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): Town of D40EL5 <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road 9D W <br /> A) 1. ❑New System 2. 'Replacement 3. ❑ Replacement of 4. ❑Addition to Parcel Tax Numbers) <br /> S stem Tank Only Existing S stem 63 <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type 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 /> +;D N� <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 /> ❑ ❑ Cl ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> &� ,✓ 22sssi S - J07 <br /> Plumber's Address(Street,City State,Zip Code) <br /> 2.7760 3S W�BST�K l,Jl- 54$93 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued I ui g Age ature(No stamps) <br /> YApproved ❑Owner Given Initial Adverse Surcharge Fee) �� <br /> Determination v U <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> I <br /> SBD-6398 807/00 <br />