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i ' rj � l� <br /> UP1 <br /> Safe &Buildings Division <br /> Sanitary Permit Application � ri g <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> `�sconsin See reverse side for instructions for completing this application 1 t�nA PO Box 7302 <br /> Personal information you provide may be used for secondary Madison,WI 53707-7302 <br /> Department of Commerce [privacy Law,s. 15.04(1)(m)] Y purposes (Submit completed form to county if not <br /> state owned. <br /> Attach complete plans to the county c2pZ only)for the system,on paper not less than 8-1/2 x 1 I inches in size. <br /> Count State Sanitary Pe it NumbeN ❑Check if r vision to previous application State Plan I.D.Numbtj <br /> Y YL Q 00 -A- `a • 5 3 0 <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner N e J I Property Location �/ 7 <br /> JI <br /> l �` 'I �1 S 0-ir 4/1/43 W1/4 S2' TJ ,N,&(or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 3 s� <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> II.Type of Building: (check one) ❑City <br /> ,& I or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): VTown of r� <br /> ❑ State-Owned u)odd �•-i le i-- <br /> 111. <br /> 'III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Ne res d S <br /> A) L ❑New System 2. lK Replacement 1 3. ❑Replacement of 1 4. ❑Addition to Parc Tax Number(s , <br /> System Tank OnlyExistin S stem Z��SZ 4,03 `70V <br /> $) Permit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑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) Elevation <br /> D 50 45 05 -� `(9o,cZ3 .10Z 05L <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 /> taQ ❑ ❑ ❑ ❑ <br /> � � Ib <br /> t /60,0r�� <br /> t,.....,.p F ► ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume res onsibilfor installation of the POWTS shown on the attached plans <br /> Plumber's ame n ) Piter's 'grata (n mps): MP/MPRS No. Business Phone Number <br /> Q 6eit ZZS�z1 7/f � <br /> hOW10-.21 <br /> Plumber's Address(Street City,State,Zi Code) / f <br /> 7?'( S- �- -, (i(f4 5 1�_'_L r W 1� S-1( _f 3 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agen igna ps) <br /> Approved ❑Owner Given Initial Adverse Surcharge F <br /> Determination -(P 12—1 l <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> �u P') Pew 1-- 1�pbc6-e, b q <br /> SBD-6398 R07/00 <br />