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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 PO Box 7302 <br /> Visconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not P-) <br /> state owned. � <br /> Attach complete plans to the coup co only)for the system,on paper not less than 8-1/2 x 11 inches in size. Lp <br /> County>V y r State Sanitary Permit Number ❑Clieck if revisio prppious appliaqion State Plan 1.D.Number 50? <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> G o re-- Q 2/` I/4 1/4,S 6[ d N,$ E or CW <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> G"104 I'91S� 9 /-O 2_7 59 <br /> II.Type of Building: (check one) ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: -2, _ ❑Village <br /> ❑ Public/Commercial(describe use): Wgown of G <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearer oad <br /> A) 1. ❑New System 1 2. Aeplacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Only Existing System Da and <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 154rolding 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.8.) (Min./inch) Elevation <br /> '3p o <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 structed <br /> Tanks Tanks L <br /> /hJ OOJ ❑ ❑ ❑ ❑ <br /> Cl ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,ed,assume responsibility for installation of the POWTS shown on the attachedTans. <br /> Plumber's varn ( nt) Plumber's Signature(n tamps): MP/MPRS No. Business Phone Number <br /> AJ A � a -�ae/n7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> QoX s 5/ S�i e -✓ w S5j 2 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Perini ee(Includes Groundwater Date I ued Issuing A ent Sign s) <br /> pp roved ❑Owner Given Initial Adverse Surch Fee \ `O / <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br /> E <br /> I0N_ U/yr, <br />