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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 /> `�sconsin See 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 30 <br /> state owned.) <br /> Attach complete plans([o the county copy only)for the system,on paper not less than 8-I/2 x 11 inches in size. <br /> Countyr State Sanitary Permit Number ❑C if re on to revious lication State Plan I.D.Number <br /> 2 r <br /> I.Application Information-Please Print all InformationLocation: <br /> Property Owner N e Property Location <br /> 70 <br /> R D #e ri 1/4 1/4,S33 7;�/D,N,R E(ornW <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 71,d A-) e — <br /> City,State Zip Code Phone Number <br /> _ Suio <br /> bdivisn Name or CSM Number <br /> Gt)e�s <br /> II.Type of Building: (check one) ❑City <br /> M_ 1 or 2 Family Dwelling-No.of Bedrooms: 2 ❑Village <br /> /11Public/Commercial(describe use):_ Mown of <br /> ❑ State-Owned ��2� <br /> Nearest Road....,�CC <br /> 3- <br /> Pal Tax Numbers) _ O OCU <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. eplacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) <br /> ❑A Sanitary Permit was previously issued Penni.Number Date Issued <br /> IV. Type of POWT System: (Check all that apply) <br /> rte' 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 J.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 /> -30 o �O a Ldp <br /> ; s <br /> VII.Tank Capacity inTotal of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Ta#nks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> 75-0 <br /> urn SL �� ❑ ❑ ❑ ❑ <br /> VZIL 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 Signa no stamps): MP/MPRS No. Business Phone Number <br /> (i 4 ZZ7 'X <br /> rMlimeerr's Address(Street,City,Stair,Zip ode) <br /> /U 0 X ,j/ S//'e/J vy' �— <br /> IX.County/Department Use Only <br /> 1 ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing nt Signa o stamps) <br /> GP Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination .�50�(� y3 def a4 <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(1107/00) <br />