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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 /> Viscon sin See reverse side for instructions for completing this application PO Box 7302 <br /> Department of Commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> Attach com Tete lens to the coon co state owned.) <br /> P P ( ty py only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> County, Ste4 I�Al(Zaty Sanilery��Number Check if revision to previous application State Plan I.D.Number <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name <br /> Property Location <br /> rty Prope �ereMailingAddress W 1/4A)(JI14, -5q,N,R!_ <br /> 1 Lot Number Block Number <br /> 9906 we &a0 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> .0 k �kf4rk I Sjq 3a I ( bl )7/ -o asG <br /> if Type Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 2 O Village <br /> ❑Public/Commercial(describe use):_ own of <br /> ❑State-Owned /42,7, <br /> Nearest ad S 8.3d <br /> e� <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) ar I Tax Number s) 3 0-oA) 1. New 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Date Issued <br /> ❑A Sanitary Permit was previously issued Permit Number <br /> IV.Type of POWT System:(Check all that apply) <br /> KNon-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 —C--System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 0� a y y�� 7 �6 .- <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 /> 4.., soy ❑ ❑ ❑ ❑ <br /> II.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 /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issu' Age �gna stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination 71,L)/ v 2 <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />