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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 /> VVisconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [Privacy O( )1 Submit completed county Q <br /> Law,s. 15.04 1 m ( p eted form to coon 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 State S nary Permit Number heck i€re�on to 2 io application State Plan I.D.Numb LP <br /> I.Application Information-Please Print all Information Location: L,aUP <br /> Property Owner Name Property Location <br /> 6�O LLj 1/4 1/4,S A5 T—'9,N,R/�(or)40 <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State / Zip Code [Phone Number Subdivisien-Alame or CSM—Number <br /> II.Type of Building: (check one) ❑City <br /> 0— 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ ;T-Town of <br /> ❑ State-Owned 1�a <br /> Nearest Road <br /> CQL 4ITS <br /> Parcel Null <br /> ( _ <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> FB) 11 <br /> 1. ❑New 2. Replacement 3. ❑Replacement of 4. 5. 6 ❑Addition to <br /> System System Tank Only Existing System. <br /> Permit Number <br /> A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground WHolding 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(GalsJday/sq.ft.) (Min./inch) Elevation <br /> - <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 /> D/Uig" Oa U c�oU S��w ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.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 stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved 7Sanitaryrmit Fee(Includes Groundwater Date Issued Issuin Agent Signature(No stamps) <br /> pproved ❑Owner Given Initial AdverseFee) h <br /> Determinations 0� ' <br /> X Conditions of pproval/Reasons for isa proval/:: -- // � <br /> �XiS .S y ewt s �e Q( &14,1,eel .36 t'©u,S X"r' ee :s�o o� 07 0 Se tJ <br /> SBD-6398(R.07/00) <br />