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Sanitary Permit Application Safety&Buildings Division <br /> ��/► In accord with Comm 83.21,Wis.Adm. Code 201 W Washington Ave. <br /> �ISCOIfS%f PerSee reverse side for instructions for completing this application PO Box 7302 <br /> Department or 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 /> Attach complete plans(to the county copy only)for the system,on paper aot less than 8-1/2 x 11 inches in size. state owned.) <br /> Court State Sanitary Permit Number ❑C c if re ' ion to revious plication State Plan I.D.Number <br /> 0$(� <br /> I.Application Information-Please Print all InformationLocation: <br /> Property Owner Name l Property Location <br /> c / �/� C rksrCN 1/4 1/4,S Y OS,N,R1S <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 90 7� G�� <br /> City, tate Zip Code Phone Number Subdivision Name or CSM Number <br /> e lei 15'5'89 3 ( -- <br /> II.Type of Building: (check one) p City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: O Village <br /> ❑Public/Commercial(describe use):_ ;M-Town of <br /> ❑ State-Owned -owl.— � <br /> Nearest Road <br /> w B <br /> Parcel Tall <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) I ew 2. Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Date <br /> ❑A Sanitary Permit was previously issued PennitNumber 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 ❑Recirculating ❑Other: <br /> V.DisperSal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area I Dispersal Area 4.Soil Application 5.Percolation Rale 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> .3®n 5/2 3 .;z I . 7 s �6.f &/ <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 /> Tanks Tanks <br /> S' 7sa ❑ ❑ ❑ ❑ <br /> 56cl SQd ❑ ❑ ❑ ❑ <br /> I.Res onsibility 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. Business Phone Number <br /> GJe-l- -7.2.�,K <br /> Plum is Address(Street,City,State,Zip Code) Ir <br /> le,j s- 87 ;".L <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Iss ' gent Signa (No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />