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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 /> Visconsin <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> 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 system,on paper not less than 8-1/2 x 11 inches in size. <br /> Co un State Sanitary Permit Number ❑Che if revision to previoapplication State Plan I.D.Numbe <br /> GJ/'n1 4F_ <br /> I.Application Information-Please Print all Into mation Location: <br /> Property Owner Name ' Property Location <br /> e ,J (I "1/4XG_l14,S3 T.?9N,RA(or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State / Zip Code Phone Number Subdivision Name or CSM Number <br /> 4 <br /> GJc A. .5 y -3 c ) <br /> H.Type of Building: (check one) ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> 5rPublic/Commercial(describe use):, ,f yy4J 1,5"Town of <br /> ❑State-Owned i✓O Pt✓ <br /> Near Rpa j' A— <br /> Parcel Tax Numbe s <br /> —o <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) I. ew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) 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 ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground fiiBolding 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.Percoladon Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Galslday/sq.R.) (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 crete structed <br /> n <br /> Tanks I Tanks <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 nnt) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater I Date Issued Issu' Agent Signature(No stamps) <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee) / ! q <br /> Determination r <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />