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Safety&Buildings Division <br /> Sanitary Permit Application 201 W.Washington Ave. <br /> In accord with Comm 83.21.Wis.Adm. Code PO Box 7302 <br /> � SCS»SQA See reverse side for instructions for completing this application Madison.WI 53707-7302 <br /> Personal information you provide may be used for secondary purposes (Submit completed form to county if nolet <br /> Department of commerce (privacy Law.s. 15.04(1 xm)] <br /> state owned. <br /> Attach complete plans Ito the county copy only for the system.on paper not less than 8-1/2 x 1 1 inches in size. <br /> County State R i N r ❑Checki(rcvisian to previous application State Plan 1.D.Numbe <br /> :Jfr1 t <br /> 1.Application Information-Please Print all Information Location: tP <br /> Property Owner Name Property Locatwn �uI CC <br /> Tg�C .Y4 4�n �c�n n��� r 114 I/4.S Z T3$,N.R or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Lode Phone Number Subdivision Name or CSM Number <br /> .G Wer ✓7�J�/ ( ) <br /> II Type of Building: (check one) ❑City <br /> Z ❑Village <br /> 0 1 or 2 Family Dwelling-No.of Bedrooms: Town of / <br /> Public/Commercial(describe use): oAs <br /> ❑ State-owned <br /> 11.1 Type of Perri:: (Check only orc box on line A. Check box on line B if applicable) Nearest Roo dy Jf <br /> A) 1. A New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel T/ter Numbcrls) <br /> System Tank Only ExistingSystem <br /> dta r Z.114 <br /> j ��� <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 O Recirculating ❑Other: <br /> V Dispersal/Treatment Area Information: <br /> 1 Design Flow(gpd) 2.IAspersalAma 3.Disposal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(GalsJday/sq.R) (MinJineh) Elevation <br /> VI Tank Capacity in Total N of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crcte structed <br /> Tanks Tanks ,e <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII Responsibility Statement <br /> I the undersigned,assume responsibility for installation oftfic POWTS shown on the attached plans. <br /> M6ums Name(prin Plum S ( ): MP/MPRS No. Business Phone Number/ aeon S o0 <br /> Plumbers Address(Street,City,State.Zip Code) <br /> �re�e��L- Qu �'y8r39 <br /> VIII County/Department Use Only <br /> ❑Disapproved Sanitary Permit F (Includes Groundwater Issuing t stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge F D! <br /> k72 <br /> I)<termination �� <br /> IX.Conditions of Approval/Reasons for Disapproval: <br />