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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> Visconsin 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 Sani a it Number ❑ ck if vis' n to prev us application State Plan I.D.Number <br /> q o-,#U e_ ��'2 8a <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> 0 'e, ! /.t3 1/4 1/4,S 7 Ty6,N,Rj�(or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 14 03 n1 Q 5f /6 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 1-1ker4JVd ss� Y 3 ( G , , y3�-��`�32 y KGS Z-L) 0C)t,- 5 <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: -� ❑Village <br /> ❑Public/Commercial(describe use):_ JaZown of <br /> ❑ State-Owned LNearest <br /> �" <br /> aG/U 3v <br /> Vax Nu ber(s)III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) L w 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> $) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> All4on-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 S.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <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 r <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print i I Plumber's Signature(nos ps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip ode) <br /> IX.County/Department Use Only <br /> �/ ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued <br /> GB Approved ❑Owner Given Initial Adverse Surcharge Fee) to u e �� 22 <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: yr„3 <br /> BVR CZO/VovN <br /> ANTYG <br /> SBD-6398(R.07/00) <br />