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Visconsin <br /> Sanitary Permit Application Safety&Buildings stIn accord with Comm 83.21,Wis. Adm. Code 201 W. Washingt See reverse side for instructions for completing this application PO Bd 2 <br /> Department of Commerce Personal information you provide may be used for secondary purposes Madison.WI 53702 1 <br /> [Privacy Law,s. 15.04(l)(m)] (Submit completed form to coun t <br /> Attach complete plans(to the county copy only)for the system,on paper nQt less than 8-1/2 x l l inches in size, state o ) <br /> County ate Sanit P i KI ❑ ck ifvision to revio 1plication State Plan 1.D.Number <br /> I. Application Information- Please Print all Information Location: <br /> Property Owner Name <br /> Property Location ��// p <br /> Property Owner's ailing Address 1/4 I/4.S hT S.N, (or(W) <br /> D' OAKD r.6 A,/. Lot Number Block Number <br /> City,State Zip Code Phone Number <br /> Subdivision Name or CSM Number <br /> Sr_ .mac MN ( 6sr ) 4s-1- 317 �Ams <br /> II.Type of Building: (check one) ❑city <br /> I9 1 or 2 Family Dwelling-No.of Bedrooms: Z ❑Village <br /> ❑ Public/Commercial(describe use): .9'own of 1� � <br /> ❑ State-Owned ��rj <br /> III. Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road �ua <br /> A) 1. New System 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Addition to Par I Tax Numbers) <br /> System Tank OnlyExistin System 22 07- 010 <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System: (Check all that apply) <br /> Non-pressurized In-ground ❑Mound ❑ Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑ Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑ Recirculatin ❑ 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.R.) (Min./inch) Elevation <br /> 6O0 (Poo , 5 R2, s <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 /> Tanks Tanks <br /> /coo logo 1 j,/ortwEsco ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII. Responsibility Statement <br /> I,the undersigned,assume responsibility forinstallation of the POWTS shown on the attached Tans. <br /> Plumber's Name(print) Plumber's Signature(no stamps): MP/MPRs No. Business Phone Number <br /> tNA,r2p v.✓ 22585/ S - / -7 <br /> umber's Address(Street,City State,Zip Code) <br /> 2.77(00 3S" W156M WI. S4s93 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit (Includes Groundwater Date Issued Issuing. Signa a s) <br /> roved ❑Owner Given Initial Adverse Surch a Fee) <br /> Determination S Q <br /> IX. Conditions of Approval/Reasons for Disapproval: <br /> S <br /> v,Lt ets- cio-ck. <br /> SBD-6398 R07/00 <br />