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Sanitary Permit Application Safety&BuildaA <br /> n <br /> 201 W.Wase. <br /> In accord with Comm 83.21,Wis.Adm. Code 2'. See reverse side for instructions for completing this application Madison W02`isconsin Personal information you provide may be used for secondary purposes (Submit completed form toot CoDepartment of Commerce [Privacy Law,s. 15.04(1)(m)] d.) <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 /> CountyState SanitaryPermit Number Check,it revision to vious application State Plan I.D.Number <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> bfirs f— 1AWI/4SVJI/a,S S'Tya,N,R/E or> <br /> Property Owner's ailing Address Lot Number Block Number <br /> a 793 3 Toss fi /:, ,e Qr, 3 <br /> City,S Zip Code Phone Number Sabr;ives+eti-Name or CSM Number <br /> Glee L* , r,•.4T s e13 3 o ( )'R `/�Z/y V/F oee <br /> II.Type of Building: (check one) ❑City <br /> J21--1 or 2 Family Dwelling-No.of Bedrooms: - ❑Village <br /> J;tqown of <br /> ❑Public/Commercial(describe use):_ <br /> ❑State-Owned <br /> Nearest Road <br /> CGO N G <br /> Pa�c�l Tax ber(s)OdS- 16g-03-0 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ew 2. ❑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 /> )gNon-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 f <br /> ation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rats(Gals./day/sq.ft.) h) Elevation <br /> 91�1- 9J, <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 Tanks <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(p);mt) Plumber's Signature( tamps): MP/MPRS No. Business Phone Number <br /> C/ '`/N,c,�s�o�A Gr/ z -769/ �`�97� <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 t Signatu stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) a vo 00 �_ f. 2Q, .� <br /> 644 4) <br /> Determination wtM <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />