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ce r'� <br /> Safety&Buildings Division <br /> Sanitary Permit Application <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> Visconsin See reverse side for instructions for completing this application Madison,WI 5 153707-7302 <br /> Box 7302 <br /> Personal information you provide may he used for secondary purposes <br /> Department of commerce (Submitt <br /> [privacy Law,s. 15.04(1)(m)] completed form to county if not <br /> state owned. <br /> Attach complete plans to the county copy only)for the system,on paper no less than 8-1/2 x 11 inches in size. <br /> Dc <br /> Coun State Sanitary P lir{ heck' revisigg to pr vows a lication State Plag 1.D.NumbeT DC <br /> vll'Np-e'ff (� (O <br /> I.Application Information-Please Print all Inforknation Location: <br /> Property OwnerName <br /> D / Property Location c� <br /> / <br /> ,e /- "O-� l .e C. 7 A-C e, 1/4 1/4 S T/o,N R',E or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> r_�2 Arc:L, 7 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> lie J'51e 73 t116 /2 <br /> II.Type of Building: (check one) 11City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): —— P-Town of <br /> ❑ State-Owned Se e T <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> G <br /> A) 1. ❑New System 1 2. [(Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Onl ExistingSystem ©� // o d <br /> B) Permit Number Date Issued <br /> O A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground 9lviound ❑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 /> sC�Oc�t� 30� 96" <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 /> Ifi <br /> y� <br /> T1CJ ❑ ❑ ❑ ❑ <br /> II.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name Tint) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Dat sue Issuing Ag nt F <br /> stamps) <br /> 960roved ❑Owner Given Initial Adverse Surcharge Fee <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> ----------------- <br /> SBD-6398 R07/00 <br />