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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 /> Viseonsin 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 corn lete plans to the county copy only)for the system,on paver not less than 8-1/2 x 11 inches in size. <br /> Count State Sam Perini umber heck if revision to revious application State Plan I.D.Number (� <br /> I.Application Information-Please Print all Information Location: U <br /> Property Owner Name Property Location <br /> S <br /> 0-e_ 1/4361/4,J7 ZI ,N,Ik/ or <br /> Property Owner's Mailing Addressd T) Lot Number Block Number <br /> CQ,State (_ r. Zip Code Phone Number Subdivision Name or CSM Number <br /> I, .els we <br /> 1I.Type of Building: (check one) ❑City <br /> �$ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): f To n of <br /> ❑ State-Owned VIYle-e;t Y\ <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) N!oest Ry�d t ` ^� q <br /> A) I. ❑New System 2. Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numbers O <br /> System Tank Only Existin S stem j 3 t IrO <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previousl issued <br /> IV.Type of POWT System: (Check all that apply) <br /> )mon-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 (p�� Rate(Gals./day sq.ft.) (Min./inch) Elevation <br /> 12400 <br /> 17 77 <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 /> C- 1000 <br /> �C ❑ ❑ ❑ ❑ <br /> 7S�D I I fr ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume rcsponsibili4 for installat n of the POWTS shown on the attached plans. <br /> PI bee Name n ) PI bets Signa ( mps): MP/MPRS No. Business Phone Number <br /> e1 ro4� 2,Z <br /> Plumber's ddress(Street,City,State,Zip Code) / ff I <br /> Uj <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permi a(Includes Groundwater Date Issued Issdn gent am o tamps) <br /> pproved ❑Owner Given Initial Adverse Surcharge / / <br /> 14� Determination ` 7 � <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />