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Sanitary Permit Application Safety&W. <br /> Washington <br /> Division <br /> in accord with Comm 93.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> �v1Sti'aDnS,n sea reverse side for instructions for completing this application 15 Box 7302 <br /> Personal information you provide may be used for secondary purposes Medisoa,WI 53707-7302 <br /> Department of commerce04(t)(m)] (Submit completed fort to county if not <br /> [Privacy Law,s. 15. auto owned. <br /> b lete plans to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. (� . <br /> State Sanitary 't if 'sionrevious 'cation State Plan 1.D.Number X-) <br /> { (, <br /> L Application Information-Please Print all Information Location: <br /> Property Gpmr Name Property Location �p <br /> //C e— ��'/ G/� o i� 114 1/4 S SPN RK'E or OQ <br /> Property owners Mailing Address Lot Number Block Number <br /> C/a�r ow, J , l. 3 <br /> ity,State Zip Code Phone Number Subdivision Nacre or CSM Number <br /> II.Type of Building: (check one) ❑city <br /> ItL 1 or 2 Family Dwelling-No.of Bedrooms: O village , <br /> Town of <br /> ❑ Public/Commercial(describe use): , IL)'e/ <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Rwd n <br /> mac: otv� /f <br /> A) 1. ❑New System 2. ;(Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> S m Tack Only Existin S tem O mrd �� y4 <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.Dhi rsal/Treatment Area Information: <br /> 1.Design Flow(spill 2.Dispersal Area 3.Dispersal Area 4.Soil Application S.Percolation Rate 6.System Elevation 77.Fin Grade <br /> Elevn <br /> Requir!d Proposed Rate(GalsJday/sq.R) (Mia/inch) <br /> VL 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 I Tanks <br /> t -f� C �4Ci i4Udq ❑ q ❑ <br /> q 1-3 ❑ ❑ <br /> 6p0 <br /> VIA.Resp nsiblUty Statement <br /> I,the undersi osume ibili for installation of the POWTS shown on the attached plans. <br /> Plumber's Num(print) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> Plumbah Address(Street,City,Stan,Zip Code) <br /> �— <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Data Isaumg i <br /> roved ❑Owner Given Initial Adverse $°1ei18fse Fee /'1 <br /> Determination OC <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 807100 <br />