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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 /> Visconsin 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)1 (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 11 inches in size. �y <br /> County State Sanitary Permit Number ❑Check if revision to previo application State Plan I.D.Number <br /> 44 4 7 0 _- <br /> I.Application Information-Please Print all Information Location: <br /> Property OwurName PropertyLocation3-v- <br /> /�.��1/4 X1/4,S/ TS 9,N,R E(or) <br /> Property Owner's Mailing Address Lot Number Block Number <br /> yo <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 4+*d 14-.,, SSCP, S3 ( �/S ) Y//- <br /> Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> I3C Cown of E S <br /> ❑Public/Commercial(describe use):_ <br /> ❑State-Owned <br /> Nearest Road//- <br /> Parcel Tax Numbers, _O t - ��Q <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 Sy tem Tank Only Existing System <br /> B) Permit Number Datelssued <br /> ❑A Sanitary Permit was previously issued <br /> IV Type of POWT System: (Check all that apply) <br /> Kon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> essurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculati �j ❑Other: <br /> v5 ZZ <br /> . - tnn <br /> .r 1 A, s <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 T in Gradc <br /> Required Proposed Rate(Galslday/sq.ft.) (Min./inch) Elevation <br /> `1s6 �` 3 (08Z , -7 — 91. 4 9s V <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 /> F �: r X 00 4 f � 'd t/.r ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown ed plans. <br /> tier's Name(print) Plumber's Signature(no tamps): Business Phone Number <br /> a� k r ,�dw ti a-s Z,2-Z&7z- y7Z-Z//- <br /> Plumber's Address(Street City,State,Zip C ) <br /> ZA-11/. <br /> IX.County/Department Use Only <br /> ❑DisapprovedSanitary Permit Fee(Includes Groundwater Date Issued Is a ignature stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination 5 -O —Q3 <br /> Conditions of Approval/Reasons for Disapproval: l RECEIVED <br /> P11'i 7 2003 <br /> B <br /> SBD-6398(R.07/00) ZONING ,- <br />