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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 /> ��seonsin See reverse side for instructions for completing this application 15 Box 7302 <br /> Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce (Submit completed form to county if not " <br /> [Privacy Law,s.15.04(1)(m)] state owned.)_ �141••- <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. 1 <br /> Cour ,o S Sani i Number ❑C k if revision to previous application State Pl I.D.N er N <br /> Fr y/'N C oZ <br /> L Application Information-Please Pri all Information Location: <br /> Property Owner Name Property Location <br /> Itl f} A.)Ze_E_ SCti✓ �.tl 5o 1/4 ua S? T/b N,R E w <br /> Property Ownces Mailing Address _` Lot Number Bck loNumber <br /> S _5"qD 4/ ti T - I G, L -2- .—. <br /> City,stateZip/ Zip Code Phone Number ubdivision Name or CSM Number <br /> II.Type of Building: (check one) ❑city <br /> C31 or 2 Family Dwelling-No.of Bedrooms: 13 Village <br /> ❑ Public/Commercial(describe use): mown of <br /> ❑ State-Owned �C <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) area °ftdC �� <br /> A) 1. ❑New System 2. fid:jieplacentent 3. ❑Replacement of 14. ❑Addition to creel Tax Number(s) <br /> System Tank Only Existing System o/ C' y CJ <br /> B) Permit Number Date Issued <br /> 11A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> ❑Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground )Uolding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other, <br /> V.Dis ersal/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 /> 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 /> / d ❑ ❑ E3 ❑ <br /> 13 ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached S. <br /> Plumber's Name(p xi Plumlxt's Sigriature 03 ): MP/MPRS No. Business Phone Number f <br /> (NAde- /1 N 4: 7k pN (�cro�- 276 r1 — 7-2-99 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Dant����e1111 Issued las Agent Signa (No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee ^, I <br /> Determination ,(�U I lV ✓ <br /> IX ond��ions of Approval/Reasons for Disapproval: <br /> uM �o o"4del� � �f see t'4ek mef�r �S <br /> res s <br /> S"8 R07/00 i SEP JOO� <br /> EURNE7'r COU <br /> ZONING�NTY <br />