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' i„j i,t t..6✓s v i r i.i:L i-V.:3 k.sr't..4 'z :.IS <br /> • Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> \ iSCOflSIflSee 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 /> County ' <br /> State Sanitary Permit Number 0 e k if revision to previous ap lication State Plan I.D.Number . <br /> py✓-tt; d 460975 ('p, c(?0) /0/ 7211 C. <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> f\----°/C eL) 6_—:--7--, (._k_re,-,..) <br /> , ee 1/45. 1/4,S,�>I',,/,N,R�E(ollryj <br /> Property Owner's Mailing Address Lot Number Block Number <br /> -2q r 5-5- 4/4,JR. r- /2J -_. -- <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> C4 i^if.J s‘,4.^5 w.T S v,y ye ( )6 ,-...2?.,9/ .------ <br /> II.Type of Building: (check one) 0 City <br /> F1' 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ ---- 4�Town of <br /> 0 State-Owned /,iii / ors!1 r,t'+i--✓i <br /> Nearest Road c f //gr` -- <br /> Parcel Tax Numlf r(s)gQ 353 j 3 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) (j-f-nt.�Q�_,?QI_13- -t.o �X�Q 0`17(teo <br /> A) 1. New 2. 0 Replacement 3. 0 Replacement of 4. 5. O Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> 0 A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> 0 Non-pressurized In-ground4ound 0 Sand Filter 0 Constructed Wetland <br /> 0 Pressurized In-ground 0 Holding Tank 0 Single Pass 0 Drip Line <br /> 0 At-grade 0 Aerobic Treatment Unit 0 Recirculating 0 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) qq 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 /> Tanks Tanks <br /> ff <br /> 5.e/Tic 7:)-0 <br /> 750 O 1 ❑ ❑ ❑ ❑ <br /> y�p e(� "— BOO / <br /> 0 0 0 0 <br /> VI Respdnsibility Statement / <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name( int) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> {,#4/� 4/. 4/.-,-, l'®.,. �-d- z 76 7 .. S/7_ 7. 56 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> c X / y Sim e ,-J c,.) - 5 5/p-7... .._.. <br /> IX.County/Department Use Only <br /> • <br /> 0 Disapproved Sanitary Permit Fee Includes Groundwater Date Issued Issuing Agent Signature(No stamps) <br /> )Lipproved 0 Owner Given Initial Adverse Surcharge Fee) y Determination / '13 ( (0 GLGt 3 <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />