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Sanitary Permit Appllcatton Safety&Buildings Division <br /> ' In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instmctions for completing this application PO Box 7302 <br /> iseonsin personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce Submit Com leted form to coon tf not <br /> [Privacy Law,s. 15.04(1)(m)] ( P tY <br /> state owned. <br /> Attach tom tete tans to the coon co onl for the s stem on a er not less than 8-1/2 x l t inches in size. <br /> County � S S 'tory Permit Number ❑Clf�k iflevis�previous application State Plan I.D.Number <br /> �uvh�P �f-� /�1 <br /> L A licatlon Informstlon-Please Print all Information Location: <br /> Property�Ojwner Name ]�'' Property Location <br /> /`.--L'h r �{�l sa e'r �Wl/4 5W I/4 S 3ST`/O,N R/SB or <br /> Properly Owners Mailing Address �Jt Number Block Number <br /> �//'�'�. '/ (rGvT 4uf <br /> �"� 3 G�rT`F-vlPrN ��� <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> �^a q� /�f/U. -�S/� � (oS� (o Z�$—OS7 �s�h v./G. . //(, <br /> II.Type of Building: (check one) � ❑City <br /> (]`1 or 2 Fatuity Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commereial(describe use): I$'['own of <br /> ❑ State-Owned ���S�/1 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest R n <br /> /'�a �a v d G/C <br /> A) 1. 2iCNew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numbers) <br /> S stem TankOnl Existin S stem O/ �{�.35`" O,J S?lQ- <br /> $) Permit Number Date Issued <br /> ❑A Saoi Permit was viousl issued <br /> IV.Type of POWT System:(Check all that apply) <br /> (�AIOn-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized 1n-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At- a ❑Aerobic Treatment Unit ❑Recirculatin ❑Other: <br /> V.Dis ersal/Treatment Area Informatlon: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Arte 4.Soil Application S.Percolation Rata 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals✓day/aq.ft) (Min./inch) Elevation <br /> 300 ti�� 43 t �7 3, `t 9.f9 <br /> VI.Tank Capacity in Total #of Manufacttuer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Can- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> t - 1 ❑ ❑ ❑ ❑ !� <br /> S ,� i e /ODO /o e� �/ovyi csaG <br /> ❑ ❑ ❑ a ❑ <br /> VII.Responsfbility Statement <br /> I the undersi ed assume res nsibili for installation of the POWTS shown on the attached ►ane. <br /> Plumbefs Name(print) Plumber's SigmWre( stamps): MP/MPRS No. Business Phone Number <br /> 'I!/�rS•e �k� tio/ �it��-� X76 9/ 7�s-�'4�- �.� �6 <br /> Plumbers Address(Street,City,State,Zip Code) <br /> 6 5/ l%'G� <br /> .County/Department Uae Only <br /> ❑Disapproved Sanitary Permit�e(Includes Croundwacer Date Issued I g Agent Si (No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee)�(,�� � `�'Q <br /> Detemtination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD•6398 R07/110 <br />