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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 /> Visconsin 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 owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper not le3k than 8-1/2 x i l inches in size. U <br /> County State San i a it Number ❑Che revisjgn to�revious a lic ion State Plan 1.D.Number D 1 <br /> G/y0 /V 2 e�� <br /> I.Application Information-Please Print ill Information Location: <br /> Property Owner Name / Property Location •7 <br /> ,}-/ Y C 1/4 1/4,S) 7 T5'?,N,Rt E(or) <br /> Property Own 's Mailing Address Lot Number Block Number <br /> 0/L ,?7/X 3 — <br /> City,State Zip Code Phone Number SabdWiciou Nameer CSM Number <br /> it <br /> II.Type of Building: (check one) ❑city <br /> ❑ ] or 2 Family Dwelling-No.of Bedrooms: -2 ❑Village <br /> ❑Public/Commercial(describe use):_ Town of <br /> ❑ State-Owned /f N/e� /S <br /> Nearest Road <br /> , /I2a <br /> Parcel T Nu r(s <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A)LA[O3 <br /> ew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. 1:1 Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> 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 P44olding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> L 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 /> o v - ._.. <br /> VII.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 /> ❑ ❑ ❑ ❑ ❑ <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(R stamps): MP/MPRS No. Business Phone Number <br /> / k � dom �' �� �� 9i y�-�� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee ncludes Groundwater Date sued Issuing aWSignare(No s <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) , l <br /> Determination t r v <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> Z© Q <br /> SBD-6398(R.07/00) <br />