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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> Visconsin 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 /> Coun State Sani Permit um SK ❑Cgeck if revision to previous application State Plan 1.D.Number <br /> ✓'�+1 �4 5�83 3 <br /> I.Application Information-Please Print all Information Location: yb <br /> Property Owner Name r Property Location l <br /> L A-rr G 2. � 1/4 1/4,&20TYON,R E(or <br /> Property Owner's ailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM umber <br /> H.Type of Building: (check one) ❑City <br /> l!. 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ KTown of <br /> ❑State-Owned O 4 k,1+ <br /> Nearest Road <br /> e,10e� <br /> Parcel Tax umber(s) O <br /> I11.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> ystem System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IIVType of POWT System:(Check all that apply) <br /> VNon-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 /> 3o o G a o ©o X5~0 97,E <br /> VII.Tank Capacity in Total #of Manufacturer PrefabrCon- <br /> Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- glass <br /> New Existing crete Tanks Tanks <br /> �'ao iron / Ski4w ❑ ❑ ❑ <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(print) Plumber's Signaturefilo stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> fid/' �� ..s//' e.-� G,✓� J`�y�� �- <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin en ignature stamps) <br /> 117 Approved ❑Owner Given Initial Adverse Surcharge Fee) ' ,O 3 <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />