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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 /> `�seonsinSee reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may secondary purposes be used for secon Madison,WI 53707-7302 <br /> Department of Commorce [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 l t inches in size. <br /> County State Sanitary P b Q�frk if rovi ion to p)yvious a Iion State Plan I.D.Number <br /> I.Ap cation Information-Please Print all Information Location: <br /> Property Owner Name Property Location �) <br /> 1/4 1/4'S3 T N E or W <br /> property s Mailing Address Lot Number Block Number <br /> 224S At. <br /> City,State Zip Code Phone Number Sub ' r �1 <br /> o7b S ARKSW <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: Z- ❑Village <br /> ❑ Public/Commercial(describe use): 'own of <br /> 13 � <br /> State-Owned <br /> eow <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) I. lew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tau Num s) <br /> system Tank OnlyExistingSystem Zy <br /> B) Permit Number Dae Issued <br /> 13A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> on-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 /> t.Design Flow(gpd) 2.Dispemal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.0.) (Min./inch) Elevation <br /> 40 1 ¢32 � 14 3 7. 6 <br /> VI.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 /> ❑ ❑r ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I the undersi d assume res ibili for installation of the POWTS shown on the attached lana. <br /> Plumber's Name(print) Plumber's Signaturo(no stamps): MP/MPRS No. Business Phone Number <br /> ALI; zzs s s 869- ts <br /> lumber's Address(Street,Ci ,Stere,Zip ode) <br /> 27760 -V i, gSO13 <br /> VIII.County/Department We Only <br /> ❑Disapproved Sanitary Permit Fee(Includes G_ water Date Is ed Issuin en o tamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval,-, <br /> SBD-6398 R07/00 <br />