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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 /> See reverse side for instructions for completing this application PO Box 7302 <br /> /sconsin Madison,WI 53707-7302 <br /> Department of commerce Personal information you provide may . used for secondary purposes <br /> [Privacy Law,s.15.04(1)(m)] (Submit completed form to county if not <br /> state owned.) <br /> Attach complete lana to the coup co only)for th stem on r not css than 8-1/2 x I 1 inches in size. r <br /> County State Sani it ❑ 'f revision to RLevioE s lication State Plan I.D.NumberV��t <br /> I.Application Information-Please Pr[n n o a to Location: <br /> Property Owner Name, / /� Property Location <br /> E01 W V�`�' I u 1� w Il4sW 1!4 S-Z�TyG N ' E or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code P � <br /> Phone Number Subdivision Name or CSM Number <br /> 15�1 <br /> at <br /> II.Type of Building: (check one) ❑city <br /> Jam-1 or 2 Family Dwelling-No.of Bedrooms: 2 ❑Village <br /> ❑ Public/Commercial(describe use): 51town of <br /> ❑ State-Owned \T �j <br /> �e-/l S a/t/ <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> _ <br /> A) I. )"ew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) d <br /> System Tank Only Existing S stem .PLO d Osl� DO <br /> B) Permit Number Date Isaued <br /> ❑A SanitaryPermit was viousl issued <br /> IV.Type of POWT System:(Check all that apply) <br /> R-Ition-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-trade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dia ersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Arca 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.fl.) (MinJinch) Elevation <br /> 300 y�q 3 -:2- -- 9�r'�3 101 <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> ,�fc • c OOv GOt/ j!✓ <br /> e1^t✓eS'c a ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(pri GG Plumbers Signature(no s ): MP/MPRS No. Business Phone Number <br /> �e%a / tlT��a�i>t (�raoiG .2-7j::��P/ <br /> Plurr�bees Address(Street,City,State,Zip Code) <br /> ��- <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Pemu't,Fre(Includes Groundwater Date Ise ed Issuing �Ig <br /> ps <br /> Approved ❑Owner Given Initial Adverse Surcharge F 1%4 <br /> Determination 0CACI r W <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 807/00 <br />