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Safety&Buildings Division <br /> Sanitary Permit Application 201 W.Washington Ave. <br /> In accord with Cotrim 83.21,Wis.Adm. Code p0 Box 7302 <br /> Visconsin 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 not Q) <br /> Department of commerce (privacy Law,s. 15.04(1)(m)] state owned. /rt <br /> Attach corn lete lana to the countyco onl for the stem on a er not ess than 8-1/2 x 11 inches in size. v 1 <br /> Count State Sanitary P b Chec ' drevisigq to rev' us app ation State Plan I.D.Number <br /> 4_ n <br /> Location: <br /> I.Application Information-Please Print all In o mation property Location <br /> Property Owner Name r // <br /> L. 6. C5e(CL�SO.n _fGhn r ( u{-+it-e k �Wumbeber 4 S�T Block Number <br /> Property Owner's Mailing Address . - v /_ ' / <br /> I G i e r C K' �' Subdivision Name or(CSM Number <br /> City,State Zip Code Phone Number <br /> ST- Fa L, VA SSI a- (oSl — 3 ❑city <br /> II.Type of Building: (check one) ❑Village <br /> K 1 or 2 Family Dwelling-No.of Bedrooms:c; 1)(Town of <br /> ❑ public/Commercial(describe use): s W" <br /> ( S S <br /> ❑ State-Owned Nearest oad d <br /> III.Type of Per (Check only one box on line A. Check box on line B if applicable) / I,'y 42 <br /> Parcel Tax Number(s) <br /> A) 1. ❑New System 2. 1�4Replacement 3. ❑Replacement of 4• ❑Sadition to ng System �3 a0 -O -X00 <br /> System Date Issued <br /> Permi[Number <br /> B) <br /> ❑A Sanita Permit was reviousl issued <br /> IV.Type of POWT System:(Check all that apply) ❑Sand Filter ❑Constructed Wetland <br /> gNon-pressurized In-ground ❑Mound <br /> Pressurized In-ground ❑Holding Tank El Single Pass ❑Drip Line <br /> ❑ [Jari Aerobic Treatment Unit ❑Recirculatin ❑Other: <br /> ❑At-Pre <br /> V.Dis ersal/Treatment Area Information: <br /> I.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation Elevation rade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) <br /> Sb 6S,S l.Z �7 /ao <br /> 3©O <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fi ass Plastic <br /> Gallons Gallons Tanks Con- Con- g <br /> Information New Existing crete structed <br /> Tanks Tanks ❑ ❑ ❑ ❑ <br /> X 7S0 ( WIiso K ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersi ed,assume responsibility for installation of the POWTS shown on the attached plans. Business Phone Number <br /> �JPI�u tier's Signa (n tamps): MP/MPRS No. <br /> Plumber's Name(print) 2I�2-2 7/r p&6— Qf V Dom' <br /> (s KO-er' O u�- O <br /> P umbels Address(Street,City,State,Zip Code) �� r <br /> 7 <br /> VIII.County/Department Use Only <br /> Sanitary Perm Fee(Includes Groundwater Date Issued Issuing t S' mps) <br /> EJ Disapproved <br /> Surcharge F <br /> Approved ❑Owner Given Initial Adverse �W r /� <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> 6-6398 R07/00 <br /> MAY I � zaoi <br /> BUR ZONING UNTy <br />