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�ttNa� 6h1c"VV <br /> Sanitary Permit Appiicat n Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm, Coe 201 W.Washington Ave. <br /> Visconsin <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Departi dent of Commerce [Privacy Law,s. 15.04(l)(m)] (Submit completed form to county if not <br /> state owned. <br /> Attach complete plans to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> Coun State Sanitary Permit Number ❑ eck if revision to previous plication State Plan I.D.Number <br /> /Ne 7 1 <br /> I.Application Information-Please Print all Information Location: I1 <br /> , <br /> Property Owner Name / Property Location -SE <br /> W <br /> 1/4 1/4S/ TYON,R/ E or <br /> Property Owners Mailing Address Lot Number Block Number <br /> 86/941 /9,^11CC1 c1 &,L, '? <br /> City,State Zip ode Phone Number Subdivision Name or CSM Number <br /> II.Type of wilding: (check one) �7 ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): oaf T <br /> 13State-Owned `' C <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road /1r✓� <br /> A) 1. ❑New System 2. Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numbers) <br /> stem Tank Only Existing System 0/,2 ya%3 2 -220 <br /> B) Permit Number Date Issued <br /> CIA Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ONon-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 Application5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <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 /> Vie- TiG Or � �C1U pt^aresc ,� ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached tans. <br /> Plumber's Name(print) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> z 7� <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing gent Signature(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) I��/ <br /> Determination <br /> IX. onditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br /> J11 (039 195`CTD <br />