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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 /> `�sconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> 9-3 <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 /> C ty State San i egitDNumber ❑ eck if re isii000nn to previ s application State Plan I.D.Numb r <br /> eelAIAh <br /> I.Application Information-Please Print all Information Location: <br /> Property Own e Property Location // X4 <br /> JQ X1/4 4,S/ZTTZ?N,F[ )W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 3So/ r'e4 �O?C-ro <br /> City,State ) Zip Code p Phone Number Cy Subdivision Name or CSM Number / <br /> ki WVN IN S O 30 (7/S-) /- 3 91 4.5t�re > 1QddIrt <br /> 11.Type of Buildi : (check one) ❑City <br /> PC 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> Toof <br /> ElPublic/Commercial(describe use):_ Town <br /> ❑ State-Owned <br /> Nearest Road u <br /> P ce Tax Numb <br /> !n'�sZ —I( 700 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. 7Replacement 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 /> P,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 /> 6 q3 6 S3 . '7 9,3, s- 24 <br /> VII.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 /> ❑ ❑ ❑ ❑ <br /> Sp 41 c W / tdl-e.S-er <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibili for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(p'nt) Plu ber s Signature(nos ps): MP/MPRS No. Business Phone Number <br /> e (S �. 2--2'� Zz 7t/ G- 0 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fyp(Includes Groundwater Date Issued Issui g ent i o stamps) <br /> proved ❑Owner Given Initial Adverse Surcharge Fe <br /> Determination p " <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />