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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 /> `�Scl7lfsin See reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for secondary Madison,WI 53707-7302 <br /> Department of Commerce Y P Y ry purposes <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned.) PiPi <br /> Attach complete plans to the county copy only)for the system,on Dapmnot less than 8-1/2 x 11 inches in size. ''1 <br /> County. State San iitary Permit N tuber ❑ k if revision to revio application State Plan 1.D.Number CN <br /> I.A ca on Information-Please Print all Information cx+7 Location: <br /> Property Owner Name Property Location <br /> `v 1/4 = 1/4 N, or <br /> Prope Own is Mailing Address Lot N bet Block Number <br /> 27S61 60- Rv F LO �-r <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> WI s6� 3 <br /> It.Type of Building: (check one) 13 city <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑village <br /> ❑ Public/Commercial(describe use): Town of W1Vf�rY <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road al <br /> A) 1. ❑New System 2. '0 Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numbe s) <br /> S stem Tank Onl Existin stem S 03 - <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 ❑Recirculatin ❑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.R.) (Min./inch) Elevation <br /> �° z q .7 9s-g 175 <br /> VI.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 /> G ❑ ❑ ❑ ❑ <br /> V I.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumbers Signature(nos s): MP/MPRS No. Business Phone Number <br /> 'w <br /> PI bens Address(Street,City,State,Zip de) <br /> Y4-760J. 93 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater D7�16 <br /> Is Issuin en a tamps) <br /> proved ❑Owner Given Initial Adverse Surcharge Fee) J <br /> ���lll���111�� Determination / <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> 7 - <br /> SBD-6398 R07/00 <br />