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SU <br /> Sanitary Permit Application Safety&Buildings Di <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington e. <br /> See reverse side for instructions for completing this application PO Box <br /> Visconsin Personal information you provide may be used for secondary purposes Madison,WI 53707 <br /> Department of Commerce (Privacy Law,s. 15.04(1)(m)J (Submit completed form to county <br /> state o <br /> Attach complete plans to the county copy only)for the s ste ,on paper not less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Permit Nu a heck ifr Mmtp previous applic ion State Plan[.D.Number <br /> Euokr I . aOct <br /> I.AppTication Information-Please Print all Infor ation Location: <br /> Property <br /> .Owner Name ^^'' ,, Property Location <br /> AU <br /> J LU's I/4 1/4,S T 40,N,R(SE o nW <br /> Property Owner's M ding Address Lot Numbe Block Nu be <br /> 27S3�1 SIFFFR18s 3 of 040r, <br /> City,State Zip Code Phone Number SubdivisiodName or CSM Number 2A/ <br /> !S > 36 <br /> II.Type of Building: (check one) ❑City <br /> I or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑ Public/Commercial(describe use): :RfTown of S4 UV AI <br /> ❑ State-Owned r1"^ i <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road &C?K sK <br /> A) l. '�M New System 1 2. ❑ Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numbers) <br /> System Tank Only Existing System © 00-0,3-x 0Q <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> 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 S.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 91 q.0 o Is .-- q S -o 1 97. 3 <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New I Existing crete structed <br /> Tanks Tanks <br /> S c 1000 ,. )Oo v NCIKSCo ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> 1,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 /> l"?v AV16,4015 ?ZSSSJ S- - /S7 <br /> umbe's Address(Street,City State,Zip Co e) <br /> 2.776035- WEam 54893 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permr ee(Includes Groundwater Date I ue Issui ent S a o mpsl <br /> ved ❑Owner Given Itritial Adverse Surcharge Fee , <br /> Determination W (� <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />