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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 /> `�SConS�n 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 the system,on paper not less than 8-1/2 x I I inches in size. <br /> County State anitar crroid be Check if revision to p vious application State Plan I.D.Number <br /> &If 7-1541 �3 /0049L3 <br /> I. Application Information-Please Print all Information Location: <br /> Property OwnerName ropee7�q on I <br /> O I9 <br /> ( . 1 LA .3.74 G:'.f FLt 1/4, TM,N,140 <br /> Property Owner's Mailing Address � G N Block Number <br /> �'3 38 f/o 0/ <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> �►"e,n 1 94Sr7a ( 7/.' > -����• <br /> II.Type of Building: (check one) ❑City <br /> A 1 or 2 Family Dwelling-No.of Bedrooms: c;L ❑Village <br /> ❑Public/Commercial(describe use):_ yd Toowwnn of <br /> ❑ State-Owned f/ww,,'V:� /J <br /> Nearest Road � <br /> a /A aC <br /> Parcel Tax Nu b (s) <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. aKeplacement 3. ❑Replacement of 4. 5. 6. ❑ Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground AHolding 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 Ara 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) p Elevation <br /> 31Dc' Zee l �ad w� — /�C� /do.0 6 <br /> VII.Tank Capacity in Totfil #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Informaiion Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks I Tanks L <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of kie POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's r' ignatu (no s ps): /MP No. Business Phone Number <br /> �- .Si�.ser 7h1 3.PL>0 7 7/,'-517W- 7. <br /> Plumber'sdress(Stye t,City,State,Zip Code) <br /> ��r / L �- <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issui Age ignatu stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) 2 t <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R 07/00) <br />