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0 Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code YA'/ 201 W.Washington Ave. <br /> See reverse side for instructions for completing this applicati n ..1 PO Box 7302 <br /> �`SC�hs�A Personal information you provide may be used for secondary pu oses Madison,WI 53707-7302 <br /> Department of Commerce <br /> [Privacy Law,s. 15.04(1)(m)] S•9 mit completed form to county if not <br /> state owned.) <br /> Attach complete plans(to the county copy o ly)for the system,on aper not less than 8-1/2 x 11 inches in size. <br /> County �i211� State Sanita>4/Pg_i—I Number ❑ 41- .�if S to revious application $D ty PI�i I)i i�iu�er /�4- <br /> I.Ap cation Information-Please Print all Information OS/ (Lo/Yc/,attiioon: //l� No <br /> PropertyOwner Name Property Location <br /> y /� Q <br /> OiqJ �. ik- 1/4 1/4,S2IT37N,IdE(o'e <br /> Property Owner's Mailing Address Lot Number <br /> 1 <br /> , <br /> City,State ZipCode Phone Number Subdivision Name or CSM Number <br /> fWI S4' 4o ( 'PC )'327-5-76c <br /> II Type fBuilding: (check one) 0 City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 4- 0 Village <br /> ❑ Public/Commercial(describe use): Town of .•af"y�„ <br /> ❑ State-Owned <br /> JKrj <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. 0 New System [2. Replacement I <br /> 3. 0 Replacement of 14. 0 Addition to Parcel Tax Number(s) ',�t <br /> System Tank Only Existing System 0 —f 52-j- (.31 -7! U <br /> B) Permit Number Date Issued <br /> 0 A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> ❑Non-pressurized In-ground Mound 0 Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground 0 Holding Tank 0 Single Pass 0 Drip Line <br /> ❑At-grade 0 Aerobic Treatment Unit 0 Recirculating 0 Other. <br /> V.Dispersal/Treatment Area Information: <br /> I.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade _ <br /> Re uircd Proposed Rate(Gals/day/sq.ft.) (Min./inch) Elevation <br /> (coo (0oe 60-2.- r.o .•,.. 114.0 ll5-0 <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing cretestructed <br /> Tanks Tanks <br /> 5IPrzt- 79) !25D loco 2. 7 oAn <br /> (000 ❑ ❑ ❑ ❑ <br /> P4 9Z, I7- ) 175. - te r✓/!/that" 0 0 0 0 <br /> VII.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(no stamps): MP/MPRS No. Business Phone Number <br /> umber's <br /> /� ,a/S �� ix,,,,4,;,, , ,22585/ 7/.' f,‘4- 1/S7 <br /> umbers Address(Street,City State,Zip C e) <br /> 7-176o Hwy 3S WEBSrez , W!• 54893 <br /> VIII.County/Department Use Only <br /> 0 Disapproved Sanitary Permit a (Includes Groundwater Date I sued Issuing • t S':. f �'�.:mps) <br /> roved 0 Owner Given Initial Adverse Surcharge Fee) Oa Q� / / !, <br /> p , DeterminationQ��/`� o ! 7 �/ / // i !"��'1 <br /> IX.Conditions of Approval/Reasons for Disapproval: t <br /> SBD-6398 R07/00 <br />