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Sanitary Permit Application Safety&Buildings Division <br /> 201 W.Washington Ave. <br /> In accord with Comm 83.21,Wis.Adm. Code PO Box 7302 <br /> `�SconSin See reverse side for instructions for completing this application Madison,WI 53707-7302 <br /> Personal information you provide may be used for secondary purposes (Submit completed form to county if not <br /> Department of commerce [Privacy Law,s. 15.04(1)(m)] <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper not le than 8-1/2 x 11 in <br /> in size. <br /> County State Sanitary rc:i u b3 ❑ eck if ion to previo�appli tion State Plan I.D.Number <br /> I.Application Information-Please Print all Information Location: <br /> [property <br /> rope Owner Name Property Location 7 <br /> 6 W '+/%J 1/4 1/4,S/ T,?S N,R, E(or) <br /> OWneils Mailing Address C, Lot Number Block Number <br /> .9416// A ,4/✓.e Tc.) .vso^J C �6"C. 5 <br /> City,State Zip Code Phone Number Subdivision Name dr CSM Number <br /> II.Type of Building: (check one) ❑ tty <br /> ZZ ❑Village <br /> ti(— 1 or 2 Family Dwelling-No.of Bedrooms: [-Town of <br /> ❑Public/Commercial(describe use):_ <br /> ❑State-Owned <br /> Nea/re�st Road l <br /> Parcel T�ax�IWnber s) O 2 Lod- <br /> 111. <br /> oUIII.Type of Permit: (Check only one box on line A. Check box on line B if applicable) EE�� <br /> A) 1. ❑New 2. placement 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 /> ❑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 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 /> 30J < 7, 2 <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 /> 750 <br /> Sov <br /> ❑ ❑ ❑ ❑ <br /> II.Resp nsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber s Name l pri t) Plumber s Signature(no tamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> /� t S c/ <br /> LdoX S/y S /Te° � �.✓� <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Pemut F%(Includes�'Zdvater Date I sued Issuing nt Si pproved ❑Owner Given Initial Adverse Surcharge Fee)Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R 07/00) <br />