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Sanitary Permit Application Safety&Buildings Division <br /> S g. <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.WaPtO Box 73v <br /> `�SI onS,n See reverse side for instructions for completing this application Madison WI 53707-7302 <br /> 02 <br /> Department of Commerce Personal information you provide may be used for secondary purposes <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned. <br /> Attach com tete plans to the county copy one for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> County State ani Permit Number Check if revision to previous application State Plan 1.D.Number <br /> L Application Information-Please Print all I formation Location: <br /> Pro"er Name ` Property Location <br /> 0 �y(� � t� , 1/4 7 1/4 T N R or <br /> Property Owner's Mailird Address Lot Number Block Num <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> VW14awl maj e- 5*1 4&r '3 1/`— P_F> 72 <br /> II Type of Building: (check one). ❑City <br /> O 1 or 2 Family Dwelling—No.of Bedrooms: ❑Village <br /> O Public/Commercial(describe use): Town of 49.496"51-0.6-D <br /> O State-owned <br /> III Type of Permit: (Check only one box on line A. Check box on-line-B if applicable) Nearest Road <br /> A) 1 1. ❑New System 1 2. Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Only Existing System C3C! 24— rDate <br /> B) Permit Number Issued <br /> A SanitaryPermit was previouslyissued <br /> k�V.Type Of POWT System: (Check all that apply) <br /> on-pressurized In-ground ❑Mound [3 Sand Filter ❑Constructed Wetland <br /> ❑ urized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating KOther. fi/O L W045"2 <br /> V Dis rsaVTreatment Area Information: e) <br /> 1.Design Flow(gpd) 2.DispersalArea 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Fired Grade <br /> Required Proposed Rate(Gds./day/sq.ft.) (Min./inch) Elevation <br /> 360 clL S4 25D I /,A T_ ?;7 - a qs_ Q'. <br /> VI 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 /> VII Responsibility Statement <br /> I the undersigned,assume res on ibility for installation of the POWTS shown on the attached plans. <br /> Plumbers Name(print) Plumb ature o s MP/MPRS No. Business Phone Number <br /> - 0;D2 1 <br /> Plum s Address(Street,City,State,Zip Code) <br /> 6.7 . S Qom ' 0 <br /> VM County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Is i g Agent Signature(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) a�D" n 13-6/ <br /> Determination ? <br /> DL Conditions of Approval/Reasons for Disapproval: <br />