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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 /> r <br /> `�SCO/fSin l information <br /> reverse side for instructions for completing this application PO Box 7302 <br /> Personal you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed forth to county if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x I I inches in size. <br /> Con State San a 't Nu ber DX4ck if ye isio to previous plication State Plan 1.D. umber <br /> I.Application Information-Please Print all Information Location: <br /> Property(Tuner Name Property Location <br /> 1/4 1/4,S-ZYT 5/-A,N,R/E(or) <br /> PropertyOwner's Mailing Address -he0inn+ber Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Type ofBuilding: (check one) ❑City. <br /> 11.e 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ 0-Town of <br /> ❑ State-Owned <br /> Nearest <br /> Parcel Tax Numbers 7 ao <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> FB) <br /> I. ❑New 2. eplacement 3. ❑Replacement of 4. 5. 6. 11 Addition to <br /> System System Tank Only Existing System <br /> 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 0mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground 0 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 Grade <br /> q6oe Required,_ _ Proposed Rate(Galsld�q.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 /> 13 0 <br /> yit7 c �'Gl s(nU ❑ ❑ ❑ ❑ <br /> Il.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Na/me(pri t) Plumber's Signature(no tamps): MP/MPRS No. Business Phone Number / <br /> 01 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Penn' a(Includes Groundwater Date issued Issuing Age Sign ture ps) <br /> proved ❑Owner Given Initial Adverse Surc a S 0, <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: A lad <br /> SBD-6398(R.07/00) <br />