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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 /> `Osconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce (Submit completed form to county if not <br /> [Privacy Law,s. 15.04(1)(m)] <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. state owned.) <br /> CountyState SanitaryPermit Number ❑heck if revision to previous application State Plan I.D.Number <br /> /^nt c (01g C a 3 WDA 9j <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name / Property Location (U <br /> �47 F 1/4/r., /4,S T3 ,N,R/ E(o W <br /> Property OwnerW Mailing Address Lot Number Block Number <br /> 73� i3 t� s <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 11 <br /> /1/1d 6-5-3y,�?- ( > <br /> II.Type of Building: (check one) ❑City <br /> J;(--i 1 or 2 Family Dwelling-No.of Bedrooms: oz ❑Village <br /> ❑Public/Commercial(describe use):_ ;�40wn of <br /> ❑ State-Owned <br /> Nearest Road <br /> 4/SQ^J <br /> Parcel Tax 2irnbe&& B 166 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. w 2. ❑Replacement 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 /> 19�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 /> 300 �<d U 6C> v , 5— 9G.,o? —9d-3 91Y.�2 -99,3 <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 /> III.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(p j t) Plumber's Signature o stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Vode) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing A S' lure(N ps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination .7.06 23, D 3 <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R 07/00) <br />