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Sanitary Permit Application Safety&Buildings Division <br /> Vi'sconsin <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 /> Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not (� <br /> state owned.) y i <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 /> County State Sanitary Permit N mber ❑Ch f revisi n to previous p ' anon State Plan I.D.Num e <br /> U 1W er , <br /> I.Application Information-Please Print all Infor ation Location: <br /> Property Owner Name Property Location <br /> /}r 1-,+r50 .J 1/4 1/4,SV Ty/,N,T(E(or <br /> Property is Mailing Address Lot Number Block Number <br /> o// V.9.4ve (A) 15— — <br /> ity,State Zip Code Phone Number Subdivision Name orGSM-4lwaber <br /> GdpN 'Y5 ') � 5-5-50115!3 (7<3 )78�'-79;2 , ck Be,4.r 1kre- <br /> II.Type ofBuilding: (check one) ❑City <br /> 0- 1 or 2 Family Dwelling-No.of Bedrooms. ❑Village <br /> ❑Public/Commercial(describe use):_ SI`Town of <br /> ❑State-Owned GcJ/f <br /> Nearest Road r/ X7979 <br /> i ro,, /A; <br /> Parcel Tax0 ber(s) 05.. O 5-0 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. JZNew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Numb � !(0� �8I Date Is�u 6 <br /> Sanitary Permit was previously issued — (SJ <br /> IV.Type of POWT System: (Check all that apply) <br /> P44on-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 /> 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 /> "3 va y Y3 , 7 97-9;F,/ 9y.6- yq <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 strutted <br /> Tanks I Tanks <br /> S ti '/. c aov -- Oov d�wGs <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) / Plumber's Signature(no stamps): MP/MPRS No. G Business Phone Number <br /> / <br /> Plumber's Address(StreetCity,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin Agent Signature(No stamps) <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> ' C Vyr 'cax�al� *ttm"�,1uay 'R/�'I /s ©/ys�7� <br /> SBD-6398(R 07/00) <br />