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Sanitary Permit Application Safety&Buildings Divi ion201 W,Washington Ave. <br /> In accord with Comm 83.21,Wis.Adm. Code PO Box 7302 <br /> ViScOns,I1 See reverse side for instructions for completing this application Madison,WI 53707-7302 (1 , <br /> Personal information you provide may be used for secondary purposes (Submit completed form to county if not �) <br /> oeaartmenl of Commerce [Privacy Law,s. 15.04(1)(m)] state owned. <br /> Attach com fete laps to the conn co onl f the s stem on a not less than 8-1/2 x I l inches in size. <br /> County L State Sanit P it Number C eck if is'on revio application State PI I D.Number <br /> w ne]� <br /> 1. A lication Information- Please Print all Information Location: <br /> Property Location <br /> Per-o�-perty Owner Name G t '] <br /> ('`J �'�I/4 St TJ�BIockI <br /> b�v JQS N[umbcrW <br /> �f ( Lot Number <br /> Property Own ces Mailing Address <br /> K--(f t e 0 <br /> Zi Code Phone Number Subdivision Name or CSM Number <br /> Cary,State P <br /> �9-ata-{ -- — - <br /> ❑CityH. Type of Building: (check one) "j' ❑Village <br /> K I or 2 Family Dwelling•No.of Bedrooms tTown of <br /> ❑ PublieCommercial(describe use): T)Q Ale U <br /> ❑ State-Owned Ne t Road I <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) k 4h 64d <br /> Parcel Tax umber(s) <br /> A) I. ❑New System 2. ('Replacement 3. ❑ Replacement of 4. ❑isting System O — 7 "•� -700 <br /> System Tank Only — Date Issued <br /> -- <br /> B) ❑ A SanPermit Number <br /> na Permn was reviousl issued <br /> IV.Type of PONVT System: (Check all that apply) ❑Sand Filter ❑Constructed Wetland <br /> ❑ Non-pressurized In-ground ❑Mound <br /> ❑Pressurized In ground <br /> Holding Tank ❑Single Pass ❑Drip Line <br /> ❑ At- ade ❑ Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V. Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) 2.Dispersal Area 3,Dispersal Area 4.Soil Application 5.Percolation Rate b.System Elevation als./day/sq.fl.) (Min./inch) �levaelon rade <br /> S Required Proposed Rate(G <br /> V l 4.5 D fPrefab Site Steel Fiber- <br /> vi. <br /> i Capacity in Total ft of Manufacturer erP7lastic` <br /> GallonGallons Tanks Con- Con- glass <br /> Information trete strutted <br /> New Existing <br /> Tanks Tanks ❑ ❑ ❑ ❑ <br /> ��� X 7300c) LJtrser <br /> ❑ ❑ ❑ ❑ ❑ <br /> Vll. Responsibility Statement <br /> I,the undersi>ned,assume res onsibili for installation of the POWTS shown on the attached fans. Business Phone Numher <br /> Plumbces Name nn PI tier's Sigmtu e( stamps): MP/M PRS No. <br /> VelE r� Y e�4�S�3 71s- F6CZr- <br /> Plumber'sAd�drress(Street,ditty,State,Zip Code) r �tr arm fl 1 <br /> sA7 <br /> ` O �— `O C, : YI J, J T"" <br /> Vlll. County/Department Use Only <br /> ❑ Disapproved Sanitary Permit Fe (Includes Groundwater Date Issued Issuin Agent Signamrc(No stamps) <br /> .Approved ❑Owner Given Initial Adverse Surcharge Fee) �rm /4l 1�1/„—O( %/,✓1 <br /> Determination llV �J 1 I VJ l c f v <br /> IX. onditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />