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t <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> `�seonsinSee reverse side for instructions for completing this application PO Box 7302 <br /> Department of Commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> [Privacy Law,s. 15.04(1)(m)) (Submit completed form to county if not <br /> Attach Com late tans to the coon co only)for the System,on r not less than 8-1/2 x 1-1 inches in size. state owned. <br /> TWO' -r State Sanitary Permit Number Check if revision to previous a licat'on State Plan I.D.Number <br /> a / <br /> I.A nlication Information-Please Print all Information Location: <br /> Progeny ame` Property Location <br /> `e- /1 e <br /> Pro Owner's Mailing Address 1/ C"1/4 S N._4E or W \ <br /> IBLot Number Block Number o x a --__ <br /> City,State Zi Code <br /> t P Phone Number Subdivision Name or CSM Number <br /> sIre-A-) w S .�313/DO <br /> II.Type of Building: (check one) ❑city <br /> I or 2 Family Dwelling-No.of Bedrooms: C2 ❑Village <br /> ❑ Public/Commercial(describe use): --- %Town of <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest R7-15-C, <br /> ad <br /> �-` o^.J <br /> A) 1. New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Paroel Numbers� O <br /> 5 stem Tank Onl ExistingSystem Q a <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> gNon-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.Dia ersaVrreatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Arca 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> R° d P Pfov Rate(�day/sq.ft.) (Min./inch} Elevation <br /> © v o 0 6 X6. 6 TO <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 strutted <br /> Tanks Tanks <br /> S� c 756 7SD VT_ ° ° ° ° <br /> ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> 1,the undersigned,assume res nsibili for installation of the POWTS shown on the attached nlans. <br /> Plumber's Ni�e(prin�} Plumber's Signature(no ps): MP/MPRS No. Business Phone Number <br /> ;7'e lI y�s�o/ 4) a17 <br /> Plumbees Address(Street,City,State[Zip Code) <br /> fi :5 <br /> VIII.County/Department Use Only <br /> ❑Disapproved SanitaryPermi ee(Includes Groundwater DaKliaedpproved 13Owner Given Initial Adverse Sege F „\ Issuing A t Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> F <br /> SBD-6398 R07/00 _ <br /> 1 � 1L1 <br /> 111 � 1 <br /> ZONING-1 <br />