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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 /> Visconsin <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> 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 papertiot less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Permit Number ❑ ec if ision to previou application State Plan I.D.Number <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Lp j,� Property Location S�� b til 1� <br /> fW 6A t 1/4 1/4,S 1 ;113WR R E(u) <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number( /_? Subdivision Name or CSM Number <br /> t,� 1 s �'� ( i ) `i J S <br /> II. ype of Buildi g: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms:—a—_ ❑Village <br /> ❑Public/Commercial(describe use):_ <br /> ,Town of <br /> ❑State-Owned k-O \ <br /> [AarrstRoad <br /> T -'S66 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) I. ew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> Ton-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) j2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> ed Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> ? . 7 r 96 - 99 dol <br /> VII.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 I Tanks <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's N (print) PI ber's Signature o stamps): MP/1vlPRS No. Business Phone Number <br /> lumber's Address( City,State,ZipCodd) <br /> it)Kta Lo 1 b <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin Ag Signature o stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination �V V e� oI O <br /> X.Conditions of Approval/Reasons for Disapproval <br /> AUG 2 7 2003 U <br /> 7 � <br /> S13D-6398(R.07/00) <br /> ZONING <br />