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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W Washington Ave. <br /> PO Box 7302 <br /> `�SC�I/S/// See reverse side for instructions for completing this application <br /> Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <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 paper not less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Pe it Number ❑Che f revision to previous ap 'cation State Plan L D.Number <br /> f' r1ov e <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> \-TA+rd> 51.4w W�U%1/4,S.7 a38 ,N,It Lf(o6Z) <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 9S e r I --- <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> r J L Ei6SS` ( ) <br /> IL ype of Building: (check one) ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: 0 Village <br /> 0Town of <br /> ❑Public/Commercial(describe use):_ ..-- / ` <br /> ❑ State-Owned L4–P—//Ch <br /> Nearest Road <br /> Parcel Tax Nu er(s) 3 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. )"eplacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.,Type of POWT System: (Check all that apply) <br /> KNon-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 /> fav ,eq v 6e C) 1 -5-- - ?6.50 47? <br /> VII.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 I Tanks <br /> Sc c 7s a 7s6 ❑ ❑ ❑ 11 <br /> ym <br /> Sba <br /> III.Res onsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <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 /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit F (Includes Groundwater I DaIssu Issuing Ageyt Sig at o ps) <br /> Approved ❑Owner Given Initial Adverse Surcharge FecLp <br /> �Q 0o` <br /> Determination <br /> oc, 117 <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> APR 2003 <br /> ZONING <br /> SBD-6398(R.07/00) <br />