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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 /> N 6consin 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 P . Nu r „❑Check revisioq to revious lication State Plan 1.D.Number <br /> QkvnrW P- p <br /> I.Application Information-Please Print all Information Location- <br /> Property Owner Name Property Location <br /> 8k_"6 L NW 1/4 Net s k3T voN,RJ41(or)49 <br /> Property Owner's Mailing Address Lot Number Block Number <br /> Sib 1/Wd00r Ii v e- g e/ <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> ftp tewsary M/V SS-'/ 7 65'1 771 '?71'1 Viii i' It OO <br /> II.Type of Building: (check one) ❑City <br /> lQ 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑village <br /> ❑ Public/Commercial(describe use): ID Town of <br /> ❑ State-Owned ae k6o n <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road / <br /> i/C t n {„�Y' <br /> A) 1. J1 New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax umber(s <br /> System Tank Only Existing System /Z ,r / Sao <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> RI 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 ❑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) 4pov'te/I 'H'r I El v ion <br /> 4S0 643 X048 7 <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 I <br /> yb �6� s/L i4 IV � ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.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 Signature(nos ps): MP/MPRS No. Business Phone Number <br /> Ple'{RYd 16 k/n ?2Svv 745--eb0_117'/.5-7 <br /> Plumber's Address(Street,City,State,Zip ode) <br /> � ;;'7b0 /-/'- 3.S- PVrkvr S'�PeS <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Da ssue Issuing nt . a ) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) /rF q B <br /> Determination L U <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />