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Sanitary Permit Application Safety&Buildings Division <br /> Washington Ave. <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W. p0 Box 7302 <br /> � See reverse side for instructions for completing this application Madison,WI 53707-7302 <br /> ViSsconsin personal information you provide may be used for secondary purposes <br /> Department of Commerce [Privacy Law,s. 15.04(I)(m)] (Submit completed form to county if not Dj <br /> state owned.) <br /> Attach complete plans(to the county copy only)fo the system,on pager not less than 8-1/2 x I 1 inches in size. <br /> County State S�nitary P it Number peck it visions too pre us application state p��.ODD.Number <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> 06 yr I/4 1/4,SIP_ T3�',N,R l{or)®' <br /> Property Owner's Mailing Address / Lot Number Block Number <br /> 2/e9 D ,'sr'7< �.r fe iAc'ess AP01 Du�lo i <br /> City,State Zip Code Phone Number Subt ivistimNamq or CSM4umber <br /> �e14er C 4V J f��.? / ( 'j'/-3 ��� %t' cs rn vis" )b/ <br /> II.Type of Building: (check one) ❑city 1'n Cpv f- DoT 1 <br /> 1U 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑Public/Commercial(describe use):_ {r Town of <br /> � <br /> ❑ State-Owned ` RD//ao Zt le- <br /> ,y Nearest Rq <br /> ,�( �p qC�'/ t�G� S'P•'r, Lair �ee-Ss Qe� <br /> I t G Parcel Tax Number(s)., <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. JR Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <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 Gmde <br /> Required Proposed Rate(Galslday/sq.ft.) (Min./inch) Elevation <br /> VII.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 /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.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 apps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street.City,State,Zip Code) _ <br /> Ace We4-,r' 6-1 <br /> IX.County/Department Use Only <br /> ❑Disapproved I Sanitary Permit Fee(Includes Groundwater Date Iss%O Issu' ent Signa stamps) <br /> lr Approved ❑Owner Given Initial Adverse Surcharge Fee) n/ , Q.O� <br /> Deterrninatic �jV <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />