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-42 aaIW) <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington <br /> See reverse side for instructions for completing this application PO Box 7 <br /> isconsin personal information you provide may be used for secondary purposes Madison,WI 53707-7 <br /> Department of Commerce Submit completed form to coon tf <br /> [Privacy Law,s. 15.04(l)(m)] ( P county <br /> state own <br /> Attach complete plans(to the county copy only)for th ystem,on paper not less than 8-1/2 x I I inches in size. <br /> County 'y State Sanitary P7' b �]Che revis' to revious app' ation State Plan I.D.Number <br /> I.Application Information-Please Print all Information Location: <br /> Property Own/e�r Name Property Location tNR/t1Clc GLi� Tan swI/4 A,wi/4,Sot7TorProperty Ownels Mailing Address Lot Number mber <br /> 140176- /b,, "d Ave- /V. <br /> City,State Zip CodeT'( -743 <br /> hone Number Subdivision Name or CSM Number <br /> IYI, to ,ave MAI, S S3(oza2S-4JOd AeA&Cs <br /> II.Type of Building: (check one) ❑City <br /> M 1 or 2 Family Dwelling-No.of Bedrooms: .3 ❑Village <br /> ❑ Public/Commercial(describe use): 19 Town of <br /> ❑ State-Owned 04/4/q n <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> i,, <br /> A) 1. N New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System T7kmber <br /> ExistingSystem 0d 0_ y3�.7-0 3.30 <br /> $) Date Issued <br /> ❑A Sanity Permit was previouslyissued <br /> IV.Type of POWT System: (Check all that apply) <br /> NNon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 4So N 5- //40 - �i qa, 7 �. 4 <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> 96$ 96d S/�tH. ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature no s ps): MP/MPRS No. Business Phone Number <br /> /ctiw� ffe �L/nS ZZS�� 7/S- X66- 4/S"7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> at77&0 //W 3S_W'•26S1`ry u/.r S 8q3 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Perm' ee(Includes Groundwater Date Issued Issuin A nt Si Stam s) <br /> Approved ❑Owner Given Initial Adverse Surchar Fe oD a/ 0/ <br /> Determination <br /> onditions of Approval/Reasons for Disapproval: <br /> 98 R07/00 <br />