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`J <br /> Sanitary Permit Application Safety&Buildings Division <br /> S 201 W.Washington Ave. <br /> >n accord with Comm 83.21,Wis.Adm. Code 8to <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> isCOnsin Personal information you provide e use <br /> ide may be for secondary purposes Madison,WI 53707-7302 (� _ <br /> Department of Commerce Submit completed form to coup if not �J <br /> [Privacy Law,s.15.04(1)(m)] ( P county <br /> state owned. <br /> Attach complete plans to the county copy only)fow7the system,on papas4iot less than 8-1/2 x 11 inches in size. <br /> County Yih e State Seri P ❑ k if teyision re io application State Plan I.D.Number <br /> I.Application Information-Please Prin a Into matiou moo[ J Location: <br /> Property Owner Name p Property Location <br /> N ` Q 4t C � `-'1/4/t/wt/4 S6 T? N.R/ W <br /> Property Owner's Mailing Addrc s INum Block Number <br /> C� W. ©4 6o v 4f-3 <br /> City,r State Zip Code Phone Number Subdivision Name or CSM Number <br /> Tc 11 W44 et 1 144 q3 -046e-Sh'1 V I r' 4 <br /> II.Type of Buildin : (check one) o city <br /> IX or 2 Family Dwelling-No.of Bedrooms: age <br /> ❑ Public/Commercial(describe use): 7 own of <br /> ❑ State-Owned & O/(e-44 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Near w Z '/, <br /> A) 1. ❑New System 1 2. Pt Replacement 3. ❑Replacement of 4. ❑Addition to Parcel T Number(s)�� `�ov <br /> System Tank OnlyExisting S stem <br /> B) Permit Number Date Issued <br /> 13A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System:(Check all that apply) <br /> 01 Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Welland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dis ersaVrreatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Arca 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals✓day/sq.fl.) (Min./inch) Elevation <br /> 030C c).50 I Z 1. 2— 1 )V- /O , 6- <br /> VI. <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 /> e .yo x tooa ❑ ❑ ❑ ❑ <br /> VI .Responsibility Statement <br /> I the undersigned.assume re ibi ty for installation of the POWTS shown on the attached plans. <br /> Plum s Name(pri ) P tuber's Signa (no tamps): MP/MPRS No. Business Phone Number <br /> r Lz2,2 47 f�(n6-�6o <br /> Plumber's Address(Sheet,City, tate,Zip Code) <br /> .0 �` !.J•r � 3 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Grow+�water Data I ed Issuing t gnatu o s <br /> roved 13Owner Given Initial Adverse Surcharge Fee) <br /> 611 r <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />