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r- <br /> Sanitary Permit Application Safet- &Building <br /> ' In accord with Comm 83.21, Wis.Adm. Code 201 W. Washin <br /> See reverse side for instructions for completing this application PO o <br /> Wisconsin Personal information you provide may be used forseconda Madison. WI 53 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m))secondary purposes (Submit completed form to cot <br /> stag <br /> Attach complete plans(to the county copy only)for thgsystem,on paper mot less than 8.1/2 x 11 inches in size. <br /> County State Sanitary Permit N ber Ch c '��vi$joo pr_evio� pplication State Plan 1.D.Number <br /> 1344(" W S� <br /> 11.Application Information-Please Print all Inforfriatioin Location: <br /> Proper Owner Name Property Location <br /> e- S Jol-dAJ 1/4 1/4,S 2 T37 <br /> ,N, <br /> Property Owner'sMailing Address Lot Number Block Numbe- <br /> a 31/ c o /r} C_ uJ eed P 4/ 6,4 F <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> >y7`! -5p3J <br /> II Type of Building: (check one) ❑City <br /> W- 1 or 2 Family Dwelling—No.of Bedrooms:_ ❑ Village <br /> ❑ Public/Commercial(describe use): ;KFown of <br /> El // <br /> State-owned e d C7f 2— <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road193S <br /> A) I. ❑New System 2. 0 Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> system Tank Only Existing System e5/ (5 gGr7 <br /> B) Permit Number Date Issued <br /> ❑ A Sani[ary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ,pwon-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 /> li.Design Flow(gpd) 2.DispersalArea 3.Dispersal rea 4.Soil Application 5.Percolation Rate 6.System Elevation� 7. Final Grade <br /> y5-d Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) .� Elevation <br /> 5 y 6Y8 - 7 - 7, Iq <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 strutted <br /> / Tanks I Tanks <br /> OG 0 /coo10 <br /> ❑ ❑ ❑ ❑ <br /> 4/h 600 6'0d ❑ ❑ ❑ ❑ <br /> VI Responsibility Statement <br /> I,the undersigned,assume responsibility for installati -n of the POWTS shown on the attached Tans. <br /> Plumber's Name(print) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> _ZJQ�e- 1 Gtl o,W 2.2 7G 9 Y9 7�z�6 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 48 0 <br /> VIII County/Department Use Only <br /> ❑Disapproved Sanit try Permit Fee(I eludes Groundwater Date Iss d Issuing Agent Signat re(No st ps) <br /> Approved ❑Owner Given Initial Adverse Surcl arge Fee) } J <br /> Determination 1/ <br /> IX. Conditions of Approval/Reasons for Disapp oval: / <br /> S�sf 7� dao� al �'�� <br /> r <br /> SBD-6398(R. 07/00) <br />