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l;�2_000 x.7 <br /> Sanitary Permit Application Safety&Buildings Di s <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington See reverse side for instructions for completing this application PO Bo <br /> iseonsin Personal information you provide may be used for secondary purposes Madison,WI 5370 <br /> Department of Commerce <br /> [Privacy Law,s. 15.04(l)(m)] (Submit completed form to countyyii" <br /> state ojnW <br /> Attach complete plans to the county copy only)for the syatem,on paper not ess than 8-1/2 x 11 inches in size. <br /> County State Sanitary Permit Number ❑Chec evil iqq to r a p ation State Plan I.D.Number <br /> I.Aplification Information-Please Print all Infdrination Location: <br /> Property <br /> �OOwwn�er�Name �/ Property Location <br /> f�+r 6AM4 1/4 1/4,S T& N, sE or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> Z_-0A Giwgra Taw 749 <br /> City,State Zip Code Phone Numbcr 3 Subdivision Name or CSM Number <br /> DI1N WI �983o s ) RCS' o <br /> I Type of Building: (check one) 0 City <br /> I or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): jaTown of <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. ❑New System 2. Replacement 1 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) p <br /> System Tank OnlyExistingS stem i7/2 /7.� 0500 <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> a.Type of POWT System: (Check all that apply) <br /> on-pressurized In-ground ❑ Mound ❑Sand Filter ❑Constructed Wettand <br /> ❑Pressurized In-ground ❑Holding Tank ❑ Single Pass ❑Drip Line <br /> ❑At- de ❑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(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 4sti X43 648 - 1 .--- $9 . 3 q2. 5 <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 /> Qf'IG 1000 17Sb Z �IoQW;cs�,n WG ❑ ❑ ❑ <br /> 13 11I ❑ ❑ ❑ <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 stamps): MP/MPRS No. Business Phone Number <br /> �N� ,✓ ?2585/ S - /S7 <br /> umber's Address(Street,City State,Zip Co e) <br /> 2_7760 3S W�ssr l/Jl. 54893 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit F,�e�(Includes Groundwater Date sue Issui gent atur o mps) <br /> proved ❑Owner Given Initial Adverse Surcharge Fe A/) <br /> / D� <br /> Determination <br /> inditions of Approval/Reasons for Disapproval: <br />