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All .3 49 9 C7 <br /> Sanitary Permit AppLcation Safety&Buildings Di <br /> Visconsin <br /> In accord with Comm 83.21,Wis.Ad� 201 W.Washingto <br /> See reverse side for instructions for completing ts� PO Bo 0:Personal information you provide may be used for secondary purpo Sn Madison,WI 117071714 <br /> Department of Commerce `�'''*��p�pleted form to court <br /> [Privacy Law,s. 15.04(1)(m)] ter(J' <br /> state o <br /> Attach com lete lans to the court co onl )f the system,on pavernot less than 8-I/2 x 1 I inches in size. <br /> County State Sanit Pe Nu ber eck ifrevision to previou application State Plan I.D.Number <br /> EUL2_ft_ I �262S_3c_5- <br /> I.Application Information-Please Print all Informatio Location: <br /> Property Owner Name Property Location �j <br /> !✓O/V L rn re I/4 1/4.S 3 TdOIN,RAE o <br /> Property Owner's Mailing Address Lot Number ock u <br /> Gil k �� .L. ! <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Nbor W �� 30 7/5- ) - oso Of- ✓ 1 -z2 <br /> II.Type of Building: (check one) ❑City <br /> lX l or 2 Family Dwelling-No.of Bedrooms: 2 ❑Village <br /> ❑ Public/Commercial(describe use): WTown of ��"" <br /> ❑ State-Owned ('.kiaN <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. ❑New System 2. RReplacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> S stem Tank Onl Existin S stem ZD 03 dl ZOO <br /> B) Permit Number Date Issued <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 ❑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(Galsdday/sq.ft.) (Min./inch) Elevation <br /> Sao �Z� y3z 7 90 � 9�. s- <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 strutted <br /> Tanks I Tanks <br /> ll�OO ko(we'5co <br /> ❑ ❑ ❑ ❑ ❑ <br /> I <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 stamps): MP/MPRS No. Business Phone Number <br /> ;eJ40ftV0 &�Sjt4 !P':j'" A 4-= - &6, 'd"-1 <br /> umber's Address(Street,City,State,Zip C de) <br /> 27760 s 1/469V? P)I_ S¢84-_;�' <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing A ent ignature(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination <br /> IY.Conditions of pproval/ easons for Disap rov 1: <br /> �A��4k i <br /> SBD-6398 RU7;UU /� <br />