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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 /> `�SCOnSin 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 /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper n less than 8-1/2 x 11 inches in size. <br /> County State SanitaryPermitNu be r ❑Ch if revi 'on to vious )�I�ication State Plan I.D.Number <br /> r(CI <br /> I.Application Information-Please Print all Information Location: <br /> Property er Name Property Location5e,— " ) yT !(/ <br /> Property Owners Mailing Address �� RE( <br /> or) <br /> Lot Number Block Number <br /> A © X 6 l- -- <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑village <br /> ❑Public/Commercial(describe use):_ )Town of <br /> ❑ State-Owned <br /> Nearest Road <br /> (` a �c d A <br /> Parcel Tax umber(s)01 d�03-y3'3- <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> FB) <br /> 1. ew 2. ❑Replacement 3. ❑Replacement of 4. 5. <br /> System System Tank Only Existing System <br /> 6. ❑Addition to <br /> Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV'.Type of POWT System: (Check all that apply) <br /> N <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 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Galslday/sq.ft.) (Min./inch) Elevation <br /> 6 y3 Y Fl , 7 75-9`6 %.? 9p, ,0 <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 /> (C- doo — lDov / A)Orco Cs c-o Ct ❑ ❑ ❑ X <br /> VIII.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( stamps): MP/MPRS No. Business Phone Number <br /> Ph` z z 76 q/ -3Y q—7, <br /> Plumber's Address(Street,City,State,Zip Code) �y <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin A t Signa (Nos ps) <br /> R Approved ❑Owner Given Initial Adverse Surcharge Fee) ��� 1� �, <br /> Determination '"/�` <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />