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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 /> PO Box 7302 <br /> Visconsin See reverse side for instructions for completing this application Madison,WI 53707-7302 <br /> Personal information you provide may be used for secondary purposes 1� <br /> Department of commerce [Privacy Law,s. 15.04(l)(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 /r State Sani ec <br /> Permit Number ❑ k if revision to pre 'ous application State Plan I.D.N tuber <br /> I.Application Information-Please Print all Informlation Location: <br /> Property Owner Name T r/ Property Location <br /> /t 4 Vd rtJ'r'4 PS �E� ILdI145t. 14,S 2/ T3 ,N,R/i'f(or)W <br /> Prdperty Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> .;r S r ��, S S� " ( 6S1 ) S/.37- 11608* �'' t.e+ 3 LSn� �'' zC-> <br /> II.Type of Building: (check one) 7 ❑City <br /> X31 1 or 2 Family Dwelling-No.of Bedrooms: J ❑Town <br /> ❑Public/Commercial(describe use):_ [dl Town of <br /> 0 <br /> ❑State-Owned ei`'� " kc <br /> Nearest Road <br /> wed 1-. <br /> Parcel Tax Number(s) . ._Z - .ZO <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. Ill Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <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 /> q Su <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 stmcted <br /> Tanks Tanks <br /> X. 3aa1 - w r- <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIIL Responsibility Statement <br /> I,the undersigned,assume res L, <br /> for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) A tuber s Signature no stamps): MP/MPRS No. Business Phone Number <br /> (S 2z1 7/s 0-64"i0k <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin ent Signatu o stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) �� ,i( n ,02 <br /> Determination ` (1f`r() e�A Lil� <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />