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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 /> See reverse side for instructions for completing this application 15 Box 7302 <br /> `�sconsin Personal information you provide may be used for secondary purposes Madison, to county 7302 <br /> Department of Commerce [Privacy Law,s. 15.04(l)(m)] (Submit completed form to county n not <br /> state owned. <br /> Attach complete plans to the county copy only)for thq system,on paper not less than 8-1/2 x 11 inches in size. <br /> Count State Sanitary Permit N , ❑Ch if revis}on Fo previous a lication State P I.D.Number <br /> 2?C-r r'N e, �T a 3h40 <br /> I.Application Information-Please Print all Information LLocation: <br /> Property Ow r Name Property Location C'_ <br /> t <br /> Pi S R� or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Nanj"LCSM Number <br /> F-4-) 1 1--5- 3 <br /> II.Type of Building: (check one) ❑City <br /> Jffi- 1 or 2 Family Dwelling-No.of Bedrooms _ 0Toµa�ge <br /> ❑ Public/Commercial(describe use): l <br /> df <br /> ❑ State-Owned L <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Neare Road <br /> }fie "-/CIA <br /> A) 1. -New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numbers) <br /> System I Existing System 014-3 V B,_�— 55 26 Q <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System: (Check all that apply) � <br /> ❑Non-pressurized In-ground yR�yMound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit D Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application5.Percolation Rate 6.System Elevation 7.Final Grade <br /> 3 Required Proposed Rat (Gals./da ft.) (Min/inch) ^� � Elevation <br /> G ri <br /> 3- �o c q 9,s <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 /> S -� �c 7�0 7S� � ❑ ❑ ❑ ❑ <br /> Oo Svc ❑ ❑ ❑ ❑ <br /> VII Respon bility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Pluumb�ees Name(print Plumber's Signature(no stamps): MP/MPRS No. <br /> Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> '&a ; d-_ •-j <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing a S' lure ps) <br /> proved ❑Owner Givgo <br /> en Initial Adverse Surcharge F41101 <br /> v Determination U 7 <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />