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(7 <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> SConSln See reverse side for instructions for completing this application 15 Box 7302 <br /> Personal information you provide may be used for secondary purposes Madison, to county 7302 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county n not <br /> state owned. qj <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 /> CountyI State SSaannit Permit Number ❑Ch k ifre ision top vious application State Plan I.D.Number <br /> UU =fv- J <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name - Property Location <br /> 16114)t:::4/4,S ,N,R( o W <br /> Property Owner's Mailing Address Lotber ,Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> rt c 74i 3a7-- 2- <br /> II.Type of Building: (check one) ❑City <br /> )� 1 or 2 Family Dwelling-No.of Bedrooms: C�L ❑Village <br /> ❑ Public/Commercial(describe use): <br /> 'Town of <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) arest Road <br /> b <br /> A) 1. ❑New System 1 2. Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Num er(s) <br /> System <br /> Tank Only Existing System V <br /> I 6C;1 <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> birNon-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) Qp. f Elevation <br /> 0 <br /> VI.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 /> �1 Tanks Tanks <br /> Je `L X ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersi ed,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(pri 0 Plu ber's SignatureE;4 <br /> MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City, tat Zip Code <br /> VIII.County/Department Usd Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date I ued Issuing Age Si m mpg) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) O/�A � � � <br /> Determination __ lU (l I <br /> Alf <br /> IX.Condritio s o Approval/Reasons for Disapproval: <br /> rs � !�►eeGi ref �er �yy�hk Tei. <br /> SBD-6398 R07/00 <br />