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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 /> See reverse side for instructions for completing this application PO Box 7302 <br /> ARsconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce (Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the systen3,on paper not less than 8-1/2 x 11 inches in size. <br /> Coun State Sanitary Permit Numb rc> revi i n to vio�ap lica[ion State Plan I.D.Numbers / <br /> ic) �(/ <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name .� Property Location cc�� ��55tt <br /> �Ze,17a10 4J1/406 /4,S TY6N,R�E(or) <br /> Property Owner's Mailing Address Lot Number Block Number <br /> ,? 7 yyS E-. Gd.r/.rro,is Lam . <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 02 ❑Village <br /> ❑Public/Commercial(describe use):_ 7WTown of <br /> r— <br /> ❑ State-Owned tl/0�tp- /90,_,jc/ <br /> Nearest Road <br /> f(/9 we_"j <br /> Parcel Tax Number(s) <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑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 /> q"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(Gals./day/sq.ft.) (Min./inch) Elevation <br /> -,7e <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> Existing <br /> New crete structed <br /> Tanks Tanks <br /> lead / /V o rwcsc o ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) if lumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) > t� <br /> SCS m� S—� �" S//� L'� ''G/ G✓ �� / S� <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent Signature(No stamps) <br /> ❑Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />