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Safety&Buildings Division <br /> Sanitary Permit Application 201 W.Washington Ave. <br /> In accord with Comm 83.21,Wis.Adm. Code p0 Box 7302 <br /> CD/1$�� See reverse side for instructions for completing this application Madison,WI 53707-7302 <br /> Personal information you provide may be used for secondary purposes (Submit completed form to county if not <br /> nent of commerce (privacy Law,s. 15.04(1)(m)] state owned. <br /> Attach com tete lans to the coun co onl for the s stem,on a er not less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Pe 't u e Check if revision previous a lication Stale Plan 1.D. <br /> Location: <br /> I.Application Information-Please Print all Information property Location C c <br /> Property Owner Name <br /> /� � Ntl/4 <br /> I Q/� /V'e V 0.4 SC e ¢f Lot Number Block Numbet <br /> Property Owner's Mailing Address <br /> 2 15,477`l TA)-l.7 <br /> Ph <br /> Zi Code one Number Subdivision Name or CSM Number <br /> Cit ,State P <br /> 4v�� �SItjr �yg��b �,s y�-ZZyq <br /> ❑city <br /> II.Type of Building: (c eck one) .3 ❑village <br /> 9I 1 or 2 Family Dwelling-No.of Bedrooms: . 'Town of <br /> ❑ Public/Commercial(describe use): (,.1e$/ /"*r_T4 .t.4 <br /> ❑ State-Owned Nearest Road p� <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) SA,u/d,fng /. <br /> Parcel Tax Number( ^A <br /> A) 1. ❑New System 2. 1 Replacement 3. Dank Onlement of 4. ❑Addition stem Y6 "Je 2 Z O ( — Cof <br /> System <br /> Date Issued <br /> B) <br /> ❑A Sanita Permit was previously issued I <br /> Permit Number <br /> IV.Type of POWT System: (Check all that apply) Mound ❑Sand Filter [I Constructed Wetland <br /> ❑Non-pressurized In-ground ❑Single Pass ❑Drip Line <br /> ❑Pressurized In-ground ❑Holding Tank g <br /> ❑At- ade ❑Aerobic Treatment Unit ❑Recirculatin ❑Other: <br /> V.Dis ersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation rade <br /> Elevation <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) � , JS 7��' /'/' <br /> S/�S0 `ls� ySa ✓ <br /> VI.Tank Capacity in Total #of Manufacturer Prefabb CEJ/Site Steel Fiber-ass <br /> Plastic <br /> Gallons Gallons Tanks Con- Con- g <br /> Information Crete structed <br /> New Existing <br /> Tanks Tanks ❑ ❑ ❑ ❑ <br /> C� <br /> Ciba ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the OWTS shown on the attached plans. Business Phone Number <br /> Plumber's tore(n ): MP/MPRS No. <br /> Plum shame(print) /� f6 <br /> o��c � �,• 1 an J -v <br /> Plumber's Address(Street,City State,Zip Code)66 <br /> z l/sA s/ <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent Sign re tames) <br /> �1 hpproved ❑Owner Given Initial Adverse Surcharge <br /> Determination pC.7 (�l <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />