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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 /> `Msconsin 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 plans(to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Permit Number ❑Cheglyjf r�r)s to pvious application State Plan I.D.Number <br /> T/� of <br /> I.Application Information-Please Print all Information Location: 4rl G L,—Y <br /> Property <br /> tyOwner Name y� Property Location [[�� <br /> r/'r�� 1/4 1/4,S1�T/�N,R E or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> y deN I,< R , y <br /> City,State Zip Code Phone Number SubdivigiorrName or CSM Number <br /> LAA)6 w s70-1 ( ) V Spy <br /> II.Type of B (ding: (check one) ❑city <br /> XI or 2 Family Dwelling-No.of Bedrooms: / El Village <br /> ublic/Commercial(describe use):_ )MIjbwn of <br /> ❑State-Owned 60W /o A4-j <br /> Nearest Road lei <br /> Parcel Tr(s), <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) 1 <br /> A) 1. ew 2. ❑Replacement 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 /> ANon-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 /> ,Z:VIl5"--) a/ s 07 z1 f 7 9S%S 9,Z:5-- <br /> VII. <br /> I.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 I Tanks <br /> s C- �vv /o©v ,Uv rwe-sts ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(printf i Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Pemtt Fee(Includes Groundwater Date Issued Issui A nt Sign (No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee _. <br /> Determination ('� ob <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />