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gaff 00 <br /> SSafety&Buildings Division <br /> Sanitary Permit Application <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> V"Isconsin See reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for secondary Madison,WI 53707-7302 <br /> of Commerce Y P Y ry purposes Submit completed form to <br /> [Privacy Law,s. 15.04(I)(m)] ( P 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 /> County SlYani ary Permit Nu b r � Vrevi ion to previous application State Plan I.D.Number <br /> Bn <br /> ure L/[ <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> 6i^ I t/I �-e.k SC- v4NE1/a S -7 Tq0,N,R/4E(or)00k <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 794 �ilcics{�he. Rve sg <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 1nv<r Grou / , >s SSO 76 6Sl 4s7-oS46 P»YOlan /7tv�v �nrs <br /> II.Type of Building. (check one) o City <br /> A 1 or 2 Family Dwelling-No.of Bedrooms:�- ❑Village <br /> ❑ Public/Commercial(describe use): Cl'Town of <br /> ❑ State-Owned 0A <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest RoadR d <br /> 6 Yee /t"" <br /> I ver <br /> A) 1. X New System 2. ❑Replacement 3. ❑Replacement of 1 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Only Existing S stem SkO- ']/,j _ 06 <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ; LNon-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 /> 4. _10 61#3 4z4 4>9,7 93.9 96. 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 /> Se C+AA 96$ w A ❑ ❑ ❑ 0 <br /> ❑ ❑ ❑ ❑ ❑ <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 Signs MP/MPRS No. Business Phone Number <br /> Ric I-A c /uNre o s s):.3 $W, 1 -7 466—Lf/s`7 <br /> Plumber's Address(Street,City,State,Zip ode) <br /> J?;>60 Hi~ 3S" We6sfrt- wr S 3 <br /> VIII.County/Dep rtment Use Only <br /> ❑Disapproved Sanitary Permit Fe (Includes Groundwater Date Issued Issuing Age t Si o m <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee) ,�/� x,l �^ <br /> Determination (/V. 6o VV <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />