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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 /> /seonsin 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 <br /> state owned. <br /> Attach complete plans to the county copy only)for e system,on paper not less than 8-1/2 x 11 inches in size. <br /> Countyn State Sanitary Permit Number ❑ if r_ 'sion to ious pplication State Plan I.D.Number <br /> F+ <br /> L Application Information-Please Print all Inf rmation Location: <br /> Property Owner/�Name Property Location <br /> 1 r tq ��C— l t�., 1/4 1/4 S3 N R`E or W <br /> Property Owner's Mkiling Address ( Lot Number Block Number <br /> � G.4 ke <br /> City,State Zip Code Phone Number Subdivision Name or <br /> or CSM NumberA SS,,SS• AlT <br /> II.Type of Building: (check one) ❑City <br /> EL I or 2 Family Dwelling-No.of Bedrooms: �— E3Village <br /> ❑ Public/Commercial(describe use): own of <br /> ❑ State-Owned e,t✓�o� <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road r <br /> [_ a c,/ <br /> A) 1. ❑New System 2. Pekeplacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Onl Existing System 0 $r/5^0 0 SM <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previousl issued <br /> IV.Type of POWT System:(Check all that apply) <br /> Jallon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other. <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7,Final Grade <br /> Required Proposed Rate(GalsJday/sq.ft.) (Min./inch) Elevation <br /> 15-0 <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> J Tanks Tanks <br /> ]S`O T$"-O 4-4 ❑ ❑ ❑ ❑ <br /> /h OQ 5_0J SGv l� ❑ ❑ ❑ ❑ <br /> V111.Responsibility Statement <br /> I the undersigned,assume respqnsibility for installation of the POWTS shown on the attached plans. <br /> Plumbees Name(print) IPlumber's Signature stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> S51 504' 72. <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary PermiDatet (Includes CtouOdwater su Issuing t Si stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) 1a7C�> (� <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07100 <br />