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Sanitary Permit Application Safety&Buildings DUO <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washingto <br /> See reverse side for instructions for completing this application PO Box <br /> iseonsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce Submit completed form to county <br /> [Privacy Law,s. 15.04(1)(m)] ( P ty <br /> state o <br /> Attach com lete plans to the county co only)f the system,on a er of less than 8-1/2 x 11 inches in size. <br /> a. <br /> County State Sani[ P Ird u ber eck i evySion to revi pplication State Plan 1.D.Number <br /> I.App ication Information-Please Print all Inforthnfinn Location: � <br /> Property Owner Name W P perry Location (/� t1�L,�L <br /> [City, <br /> perty Ownees Mailing Address Lot umbe��l/4,S tp T ber 310 k NumberW <br /> Ito o1wrol v Rl � <br /> State Zip Code Phone Number Subdivision Name or CSM Number <br /> Uig C�inu> M�, 5/11 AID(, aVV Io AfM <br /> II.Type of Building: (check one) ❑ i <br /> 1 or 2 Family Dwelling-No.of Bedrooms: <br /> � ❑Village <br /> ❑ Public/Commercial(describe use): frown of C`� <br /> ❑ State-Owned �J <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> iJSCbiNI C <br /> A) 1. ANew System 2. ❑Replacement 3. E3 Replacement Replacement of 4. ❑Addito Parcel Tax Numr(s) <br /> S stem Tank Onl Existin S stem (o, 61 11 o <br /> B) Permit Number ate Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> aIV.Type of POWT System: (Check all that apply) <br /> on-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ressurized 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 Prop sed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 3bcl ZA 3L , -� . I G - 1 <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 /> �- )bbo -- Ivoo I 7Vd2Wt�'co <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(print) Plumber's Signature(no stamps): MP/MPRS No. �+ Business Phone Number <br /> AMA--w .✓ �ZSgJ I S- & <br /> umber's Address(Street,City State,Zip Code) <br /> 2.77(00 3S WE6sr�x WI. S4$g3 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit FebllIncludes GrourAwater I Date I uedIssuing ge i 1 o stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) ((.�]],��`\\JJ <br /> Determination Q <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />