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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 /> 4sconsin 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 /> County � p State Sanitary Permit Number ❑ eck if vision to previo s application State Plan I.D. umber <br /> 15 i- r K e'h`1'" 3 �0`2 <br /> I.Application Information-Please Print all Inforination Location: <br /> Property Owner Name Property Location 7 <br /> 4 dt u VA-- r 0 r V� GIl4 JUE14,S1j3 kN,14 7(or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> C)a-SI S4-z� a <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> S 1� � W� 5 E- ( / 5) /o89 -u�Z <br /> II.Type of Building: (check one) ❑City <br /> Q1 1 or 2 Family Dwelling-No.of Bedrooms: oZ ❑Village <br /> ❑Public/Commercial(describe use):_ fgTown of <br /> ❑State-Owned J ) CS <br /> Nearest Road <br /> 'S'S-6k rp O <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Parcel Tax Numbers .Z i -O <br /> A) 1. ❑New 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 10 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(GalsJday/sq.ft.) (Min./inch) Elevation <br /> Ob flO I 91P9 0/' o <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 /> Tanks Tanks <br /> / ❑ ❑ ❑ ❑ <br /> v <br /> x Sov � ❑ ❑ ❑ ❑ <br /> VIII.Responsi ility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumbers Name(print) P lmber's SignaMre(nstamps): MP/MPR.Sr—No. Business Phone Number <br /> ` l?e Y ��� �Z ] �i�i 7/ <br /> Plumber's Addres (Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(In lodes Groundwater Date Issued Issuin Agent Signature(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination <br /> Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />