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Sanitary Permit Application Safety&Buildings Division <br /> Visconsin <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 /> Department of Commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> [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 I 1 inches in size. <br /> County States itary,Permit Number ❑Ch 'f revis)on to previous pplication State ��1.D.Number <br /> Imo`, <br /> I.Application Information-Please Print all Information IIILocation: <br /> Property Owner Name Property Location <br /> /ps <br /> 451/4SII S Z1 T37,N,Rl CE(or W <br /> Property Owner's ailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number <br /> Subdivision Name or CSM Number <br /> v-4 L. W q (7/S ) 3 Z - 11,VY3 <br /> II.Type of Building: (check one) ❑city <br /> pt 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑Public/Commercial(describe use):_ [$Town of <br /> ❑State-Owned <br /> Nearest Road f�G / <br /> `l <br /> Parcel Tax Number(s) <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System 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 ;kMound ❑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) MI <br /> 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation T Final Grade <br /> Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> �© SD 1 1, D 97-1 <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 /> /I Tanks Tanks <br /> x /Q(JV ( ❑ ❑ ❑ ❑ <br /> r <br /> X fo�c� 1 ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibili for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plu ,bett''s SSigna ps <br /> a(no stam ): MP/MPRS No. <br /> jBusiness Phone Nu/mber[y <br /> Plumber's Address(Street ity,State,Zi Code) <br /> s Gs U w <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater 1 Date uing a Issued Issrgna o stamps) <br /> J§Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination z1 0 'p /jAll <br /> X.Conditions of Approval/Reasons for Disapproval: i <br /> >=ffL.UWT ;4L-rdEl . Is Rt5QVV b 8E �o(I Fat, ?ntxraLf sizQn = �. V % L7 <br /> of x. (to wit+., l l' <br /> Oct 1 S ?OQ � <br /> 0 <br /> SBD-6398(R.07/00) N/ryi <br />