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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 /> See reverse side for instructions for completing this application PO Box 7302 �`` <br /> isconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 w <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 /> Coun State Sanitary u e ❑Permit Nh k' re ion tq,prous applic ion State Plan I.D.Numbco <br /> I.Application Information-Please Print all Infor ation Location: <br /> Property Owner Name 1Property Location <br /> W"I CIA /4,S T 3N,R/ <br /> Property Owner's Mailing Address Lot Number Block umberW <br /> a a-!rS Co cl R a <br /> City,State Zip ode 7ho -7umSubdivision Name or CSM Number <br /> e� •� , k). S 93 S (6- c)Qa <br /> II.Type of Building: check one) ❑City <br /> J9 1 or 2 Family Dwelling-No.of Bedrooms:_— ❑Village <br /> ❑Public/Commercial(describe use):_ ;K Town of <br /> ❑ State-Owned L/ At <br /> Nearest Road /, -D <br /> Parcel Tax Number(s)G 3 qa'� j a(, <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Y <br /> A) 1. ❑New 2. Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System 16ystem 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 /> ❑Non-pressurized In-ground JKMound ❑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(GalsJday/sq.ft.) (Min./inch) Elevation <br /> qJ� ZY <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 Tanks <br /> 1(rC. Y lOb� ® ❑ ❑ ❑ ❑ <br /> x- sr ❑ ❑ ❑ ❑ <br /> VIII.Responsi ility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name nt) Plu ber s Signature no ps): MP/MPRS No. Business Phone Number <br /> I�e,Is �a*v -ev' <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 'f S CIOO1 <br /> IX.County/Department Use Only Lo <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date ssu Issuing Agent Signature(No ) <br /> Approved 11 Owner Given Initial Adverse Surc c Fee <br /> Determination <br /> X.Conditions of Approval/Reasons r Disapproval: d <br /> Pr <br /> soi/ � be- ttihrO 3e�� �a r .� 10 LJ n NOV <br /> BURNE7-1 2 002 <br /> NTNG <br /> SBD-6398(R.07/00) <br />