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Sanitary Permit Application Safety&Buildings Divi <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington <br /> See reverse side for instructions for completing this application PO Box 7 <br /> `�SCO/fSin Personal information you provide may be used for secondary purposes Madison,WI c 07-7 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county i <br /> state owne <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 State Sanitary Penni ber Check' evisi n t previo application State Plan L D.Numb O <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> R1 Sup" 1/4 1/4,S« <br /> Property Owner's Mailing Address Lot Number 318rk #"n*" <br /> jj�q7$� /l�-/E �D- S <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> a WI• .54893 7/5- 866- 4438 V. 10 P. ?s6 <br /> II.Type of Building: (check one) ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: O 11 Village <br /> Public/Commercial(describe use): W SF�413 ZrFJ�t_X, f�ES y Xrr WAW,.%6WJ0 /Fi Town of C <br /> ❑ State-Owned —5 corn <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) N ar s • Ro <br /> A) I. s tew System 2. ❑Replacement 3.±Tank <br /> placement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Onl Existin S stemB) rmit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System: (Check all that apply) <br /> Non-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 /> 5s7 11 1200 . 46 9s g 97 8 <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> G I llSb Z <br /> II.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> umbers Address(Street,City State,Zip Co e) <br /> 2-77(00 �jS (��BST�K lnr'1. 54$93 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Age atu ) <br /> 4pQroved ❑Owner Given Initial Adverse Surcharge Fee) D /> <br /> \`T l Determination v ' <br /> IX.Conditions of Approval/Reasons for Disapproval: _ <br /> SBD-6398 807/00 ('AJ Y-•r.r a <br />