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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 /> ` seonsinto county <br /> if not <br /> See reverse side for instructions for completing this application Madison, l 5 7302 <br /> Box 7302 <br /> Personal information you provide may be used for secondary purposes t <br /> oedartment or commerce [Privacy Law,s. 15.04(l)(m)] (Submit completed form o / <br /> state owned. <br /> Attach complete plans to the county copy onl for the Sys on paper no s than 8-1/2 x 11 inches in size. <br /> Cgpn,y State Sanitary Permit k if lonoqprevious ap tion State Plan I.D.Number <br /> a r lU e OCa <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location ? L, / <br /> /¢�� C.Q— / >✓ i/4 1/4 �J T7 ,N R or <br /> Property Owner's Mailing Addmssss Lot Number Block Num <br /> /7 W GS / 7�K <br /> City,S MM ZZiip�Code Phone Number Subdivision Name or CSM Number <br /> ♦ V „`/t� J <br /> II.Type of Building: (check one) ❑City <br /> 1, )or 2 Family Dwelling-No.of Bedrooms: a2 ❑Village <br /> ❑ Public/Commercial(describe use): 7YTown of f <br /> ❑ State-Owned 10A) <br /> M. <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road phi INN <br /> A) 1. New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numr�bp is) <br /> S stem Tank Onl Existin S stem — `/a: <br /> _0 �Q <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System:(Check all that apply) <br /> itNon-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 /> L.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Ates 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(GalsJday/sq.R) (Min./inch) Elevations <br /> on e %2 3 i 57:5- <br /> �� 7 �' 77' <br /> VI.Tank Capacity in Total #of ManufacturerEcretestrue"ted <br /> Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks glass <br /> New Existing <br /> TanksTanks7.Sv ❑ ❑ ❑ <br /> y/yj V SO(� <br /> II.Resifonsibility Statement <br /> I,the undersigned,assume res nsibili for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(p)) Plumber's Signature stamps): MP/MPRS No. Business Phone Number <br /> Y 9— <br /> Plumbers Address(Street,City,State,Zip Code) <br /> O X S� �S'/ /' �'lJ G✓ � 87 r2 <br /> VIII.County/Department Use Only <br /> ❑Disapproved SanitaryPemtit Fee( udes Gmund ter Da Issued Issuing A t Si re s) <br /> Approved 1 ❑Owner Given Initial Adverse Surcharge Fee) ��\ <br /> Determination V <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />