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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 /> See reverse side for instructions for completing this application PO Box 7302 <br /> `*sconsin 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.) <br /> Attach complete plans(to the county copy only)for the system,on paper of less than 8-1/2 x I 1 inches in size. <br /> Co ty ` , State 3aQtary'PJerm�tt Number ❑/ c if rov ionito pro i uus plication State Plan L D.Number <br /> c4 r <br /> I.Application Information-Please Print all Information Of�� Location: <br /> Property Owner Name // Property Location <br /> f}-�e- b e r.t) b ,P-r (,t)l/4/061/4,S3.3T 4,N,d E(o w <br /> Property Owner's Mailing Address Lot Number Block Number <br /> d-7ya 7 5 N A-fe_ d <br /> City,State Zip cKle Phone Number Subdivision Name or CSM Number <br /> W�bSf �91w� Z5 <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ '](Town i of � <br /> /}�/� t_ <br /> ❑ State-Owned w ' l <br /> NearesCRQad <br /> Parcel TTT umb sell <br /> o �� <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) L ew 2. m 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 /> ONon-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.ft.) (Min./inch) Elevation <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 stmcted <br /> Tanks I Tanks <br /> Sf isd00 — dOr� ❑ ❑ 11 ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(pri 0 Plumber's Signature(no ps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin t Signatu o stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) �/ <n� < <br /> Determination — [T° 5 lour W <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />