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' Sanitary Permit Application Safety&Buildings ion <br /> « In accord with Comm 83.21,Wis.Adm. Code 201 W.Washingt <br /> N iseonsin See reverse side for instructions for completing this application p0 Ane <br /> Department of Commerce Personal information you provide may be used for secondary purposes Madison,WI 53 <br /> [Privacy Law,S. 15.04(l)(m)] (Submit completed form to cou <br /> Attach nom Tete lans to the coun co onl )f the s stem,on a not less than 8-1/2 x 11 inches in size. stat <br /> County State S P 't tuber <br /> ck if ygvisi n to previo application State Plan INumbcr <br /> I.A .icatOn Information-Please Print a 1 In ormation <br /> Property Owner Name Location• <br /> ED4rA Ll I� Property Location M <br /> Property Owners matitiing Address �(',. 1/4 1/4,S I2-7 ,N,44� or <br /> TIZERSuRES- �fl- Lot Number Block Number <br /> City,State Zip Code 112 <br /> �( A lA _ Phone Number Subdivision Name or CSM Number <br /> 1/ {�(�t�►z _ �4 83o t S ,25 3-7o fRE2 4514gfE Ss .Aon. <br /> I*vAI Type of Building: (check one) <br /> lit 1 or 2 Family Dwelling-No.of Bedrooms : ❑City <br /> ❑ Public/Commercial(describe use): ❑Village <br /> ❑ State-Owned �SrTown of -V O <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest R°a <br /> A) L ❑New System 2. replacement 3. ❑ Re lacement of 4. Addition to <br /> Parcel; umbers) <br /> B) <br /> S stem Tank Onl Existin S stem (fl Z.�' <br /> Z �L7 <br /> ❑A Sanita Permit was reviousl issued Permit Number Date Issued <br /> IV. Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground ound <br /> ❑ Pressurized In-ground ❑ Sand Filter ❑Constructed Wetland <br /> ❑At-grade ❑ Holding Tank ❑Single Pass ❑DripLine <br /> ❑Aerobic Treatment Unit 13 Recirculating <br /> V.Dis ersaUTreatment Area Information: ❑ Other: <br /> I.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area <br /> Required Proposed ed 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Soo P Rate(Gals./day/sq.R.) (Min./inch) <br /> `�D� 30 ' Elevation <br /> VI.Tank 1 .0 q4- 1 S.9 <br /> Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks <br /> New Existing Con- Con- glass <br /> Tanks Tanks I trete strutted <br /> sE « 750 75n ❑ ❑ ❑ ❑ <br /> Soo ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> 1,the undersi tied,assume res onsibili for installation of the POWTS shown on the atans. <br /> Plumbermss Name(print) Plumber's Signature no sta <br /> P ) MP/MPRS No.ttached r Business Phone Number <br /> umberAdr�(Street,City State,Zip Co e) S — ��7 <br /> 2-77k 3S W66M LVI- S4$g3 <br /> VIII. County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(includes Groundwater <br /> Date Issued uedAPProved ❑Owner Given Initial Adverse Surcharge Fee) Issuin A ent Signa re(No stamps) <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: �eG <br /> SBD-6398 R_/ <br />