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Sanitary Permit Application <br /> Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> Nvisconsfn 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)] (Submit completed form to county if not <br /> state owned. <br /> Attach complete lana to the coup co only)for the system,on r not less than 8-1/2 x l 1 inches in size. <br /> County State Sanitary t if rclsiogtopOvious pplication State Plan I.D.Number O <br /> I.A cation Information-Plesse Print a f r ation ���� Location: <br /> Property Owner Name Property Location <br /> E 1/4 I/4 S Is T ,N R W <br /> Property OwnersMailing Address Lot Number Block Num <br /> A-C.,71 14OWN4, Sw DR69 <br /> - <br /> City,State Zip Code TPhoneNumber Subdivision Name or CSM Number <br /> �aW1 $3o S - 2 a' RSD 1b ✓ V. <br /> Il.Type of uilding: (check one) ❑City <br /> ❑ l or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): ATown Of <br /> 13 State-Owned : <br /> ACksokl <br /> Ill.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road 5Q <br /> A) 1. ❑New System 1 2. Replacement 3. ❑Replacement of 14. ❑Addition to Parcel Tax Z s O <br /> System Tank OnlyExistingS stem (�•[) <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> I .Type of POWT System:(Check all that apply) <br /> WJ4on-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 3.Dispersal Area 4.Soil Application 1 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.0.) (Min./inch) EjVvation <br /> So Q�9 9.9 <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 /> ❑ ❑ ❑ ❑ <br /> L <br /> 5� ❑ ❑ ❑ ❑ <br /> V I.Responsibility Statement <br /> I the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumb (print) A/ <br /> Plumbels signature"' 1 (no a ): MP��8�,No. BusinessPhoNum �/� <br /> umbet's Address(Street,City,State,Zip C ) S <br /> o 1 l � w• 8s3 <br /> VIII.County/Department Use Only <br /> ❑Disapproved I SanitaryPermit Fey(Includes Grou aterZlued/gwIssuing Si o <br /> ved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination I <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />