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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Cotton 83,2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> `VIseonsinSee reverse side for instructions for completing this application PO Box 7302 <br /> Department of commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 n <br /> (Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned.) v l <br /> Attach tCountYAom late tans to the coon co only)for the system,o a r not less than 8-1/2 x l 1 inches in size. <br /> State Sanitary Permit N 'sio xo pre ' ap n u State Plan I.D.Number <br /> /C1 P (� S <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> �,V/V 1/4 1/4 S T.3 ,N,R or <br /> Property Owners Mailing Address / , / Lot Number Block Number <br /> Gt1�.J�L./pr /Tve� Sr .Q <br /> catty,state Zip Code Phone Number Subdivision Name or GSM Number <br /> ,c7r[eo1N/�t, o Q152 O,-2—3 ys 14-JA)cA : cr <br /> IIJ Type of B ng: (check one) ❑city <br /> f a+1 or 2 Family Dwelling-No,of Bedrooms _ C3Village <br /> ❑ Public/Commercial(describe use): XTown of <br /> ❑ State-Owned a 0,0j <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Neares Roa /D <br /> A) 1. ❑New System2. Weplacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax umber(s) <br /> System Tank Only Existing System 01 O O O/ 70 <br /> B) Permit Number Date Issued <br /> ❑A Sana Permit was previouslyissued <br /> IV.Type of POWT System:(Check all that apply) <br /> LZNon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Welland <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 Arca 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(GalsJday/sq.R) (Min./inch) Elevation <br /> 3 " o `/� 151-3 .:2- - 9�/- 6 96'.x' <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 /> ser c V00 ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> 1,the undersianed,assume res ibility for installation of the POWTS shown on the attached plans. <br /> Plumbers Natne(print) Plumber's Signature(no pa): MP/MPRS No. Business Phone Number <br /> Plumbers Address(Street,City,State,Zip Code) <br /> ,C3v <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date I ued Issuing t Si pa) <br /> (proved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination J� p M t✓ �j 6 <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />