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• ��sCor)sin �n� ��'� <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application 15 Box 7302 <br /> onsin Personal information you provide may be used for secondary purposesMadison,WI 53707-7302 <br /> Vise <br /> Department of commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned. <br /> Attach complete plans to the county copy only)for the system,on papgr not less than 8-1/2 x 11 inches in size. <br /> County State Sani Permit Number ❑C %k if vision to previ us application State Plan I.D.Number <br /> 37 �(00 '47-a � <br /> I.Apolication Information-Please Print all Information Location: J <br /> Property Owner Name Property Location <br /> gom j 1/4 W114,1/4 S T N,PAE or W <br /> PropertyOwner's Mailing Address Lot Number Block Number <br /> 6945 OW A .L.3 <br /> Ci ,State Zip Code Phone Number Subdivision Name or CSM Number <br /> II.Type of Building: (check one) city <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: 'Y ❑Village <br /> ❑ Public/Commercial(describe use): Town of O/V <br /> NN / <br /> ❑ State-Owned C /v <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road 0� n <br /> A) 1. ❑New System 2. replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) !� <br /> S stem Tank Onl Existin S stem 019 -'5-36 03 SVa <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> on-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 /> 300 (oo 00 -s- <br /> VI. 90. ¢..�' <br /> 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 /> 75V -75D <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume res on ibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no sta ps): MP/MPRS No. Business Phone Number <br /> 1�/�ARt7 f{nP,r�✓�/S 12585! <br /> 7157-966- 41507 <br /> Plumber's Address(Street,City,State,Zip ode) <br /> 2,77 6n3s WC5s�2, w f 5489 3 <br /> VIII.County/Department se Only <br /> E3 Disapproved Sanitary Permit Fe (Includes Groundwater Date Issued Issuing gent Signature(No stamps) <br /> pproved ❑Owner Given Initial Adverse Surcharge Fce)4 s. cc) <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: i <br /> SBD-6398 R07/00 <br />