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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 a tion PO Box 7302 <br /> Personal information you vide may be used for secon ores Madison,WI 53707-7302 <br /> Department of Commerce y provide y pp1p Submit completed form to coon if not <br /> [Privacy Law,s. 15.04(i)(m)) ( P county <br /> state owned. <br /> Attach complete lana to the coup co only)for the stem on paper not 1 s than 8-1/2 x 11 inches in size. <br /> County Attach <br /> Sanitary P7ni <br /> gu.116Penni 7 P i viaitpyto yioa 1' tion State Plan I.D.Number L <br /> L Application Information-Please Print all Information L F Location: <br /> Property Owner Name Property Location MM <br /> Property Owner's Mailing Address WE 1/4SbJ 1/4 S IST N or W <br /> l� <br /> Lot Number Block Number <br /> -*2jS5l r, <br /> City,Slate Zip Code Phone Number Subdivision Name or CSM Number <br /> ffiv• S5 22 37 S <br /> I Type of Building. (check one) �7 ❑city <br /> 1 or 2 Family Dwelling-No.of Bedrooms: !r ❑Village <br /> ❑ Puhlic/Commercial(describe use): 1WTown of <br /> ❑ State-Owned QAlLLf�Np <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) I. New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Onlv Existing System Q 3(G—Q — 0 <br /> B) Permit Number Date Issued <br /> 13A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System:(Check all that apply) <br /> on-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 /> t.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(GalsJday/sq.ft.) (MinJinch) Elevation <br /> o Is 94 8q7.7 <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 1616 <br /> G 1� ❑ ❑ ❑ ❑ <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(no a MP/MPRS No. Business Phone Number <br /> PlumbeeS Address(Street,City,State,Zip C ) <br /> V bo t. qv <br /> VIII.County/Departm&ent Use Only <br /> ❑Disapproved I Sanitary Permit Felyncludes Gro dwater Dat=Pd1ssu_mgAgentSiAYRtUM <br /> ed ❑Owner Given Initial Adverse Surcharge Fee) ,,,\Determinatio (y{J <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07M <br />