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Sanitary Permit Application Safety&Buildings Division <br /> ' In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> V iseonsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 (� <br /> Department of Commerce [Privacy Law,s.15.04(1)(m)) (Submit completed form to county if not )C_J <br /> state owned.) <br /> Attach complete plans to the county copy only)for Ike system,on a an not less th8-1/2 x I I inches in size. <br /> County N r State Sanitary it if reyiyio to ions a 'cation State Pian I.D.Number <br /> N � <br /> L Application Information-Please Print all Information Location: <br /> Property Owner Name , / Property Location �/ (� <br /> 40,u 1/}9/ ow e- ( & 1/4 wl/4 S T N,A <br /> Property s Mailing Address Lot Number Block Number <br /> _71S0 CCCje eJ 1 . �- <br /> City.State I ,ip <br /> Code Phone Number Subdivision Name or CSM Number <br /> d�r otr y8'3 a -i <br /> II.Type of uilding: (check one) ❑city <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): ° <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest <br /> A) 1. 16d:New System 1 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Only Existing System B 02- <br /> B) <br /> El Permit Number Date Issued <br /> A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> 044on-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 Arca 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(GalsJday/sq.R) (MinJinch) Elevation <br /> Soo va 9 1 417 - �3 Iq lq6 <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> A--Z c ov DOS o res�a 11 ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I the undersigned,assume re!p2nsibility for installation of the POWTS shown on the attached plans. <br /> Plumbers Namelpprnint) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> Plumbers Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Pemtit (Includes Groundwater D to I ued Issuing Si s) <br /> proved ❑Owner Given Initial Adverse Surcharge Fee �f�l/��,M <br /> /(/j) O <br /> Determination ll V <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br /> rJ LI J <br /> BJ�r�V�T7- <br /> Z�NING UN7 Y <br />