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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code '\ � 201 W.Washington Ave. <br /> Viscons�n See reverse side for instructions for completing this application ON PO Box 7302 <br /> Department of Commerce Personal information you provide may be used for secondary purposes V Madison,WI 53707-7302 <br /> [Privacy Law,s. 15.04(1)(m)) (Submit completed form to county if not <br /> CounAttach complete Tans to the coon co only)-forstate owned. <br /> the system,on paper not less than 8-1/2 x 11 inches in size. ( <br /> ty/l N ra C State Sanitary Permit Number Chec if�re7vision to vious application State Plan I.D.Number <br /> '�J1 . O`y <br /> I.Application Information-Please Print all Informatio Location: C <br /> Property Owner Name f T�r Property Location <br /> / 5 -� <br /> Property Owner's Mailing Address 1/4 va S/YT5,?N,dor wLot Number Block Number <br /> vim( <br /> City,Stater p Code Phone Number Subdivision Name fiber <br /> Nuer c_, 6s/ <br /> II.Type of Building: (check one) p City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village Ap—ej <br /> ❑ Public/Commercial(describe use): P! Town o <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. lew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel ax Numbers) <br /> System Tank OnlyExistin System (00 oc —Q;�- <br /> sap <br /> Numbe <br /> B) r Date Issued <br /> ❑A SanitaryPermit was previouslyissued Permit <br /> IV.Type of POWT System: (Check all that apply) <br /> J"on-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 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gels./day/sq.ft.) (Min./inch) �� Elevation <br /> e9°o & y3 4/y — $, <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 structed <br /> Tanks Tanks <br /> /C rzC (JOf) -- COQ d(tdCsc;o ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Nam (print) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> �y7 ����� <br /> Plpumber's Address(street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Iss Issuin A nt S' to o tamps) <br /> A proved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 / <br /> lMAR 2 3 2001 <br /> 13URNETT COUNTY <br /> ZONING <br />