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Sanitary Permit Application Safety&Buildings Division <br /> S 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 /> iseonsin Personal information you provide may be used for secondary purposes Madison,WI 53707.7302 <br /> Department of Commerce [Privacy Law,s.15.04(Ixm)] (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 8.12 x 11 int es in sift. <br /> County Side Sed cmut umber O Cppe if revision to vious application State Plan 1.D.Number <br /> T I �q a-- <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner N°�'` Properly csuon <br /> def o /71 E1/4N61i4,s TWN,An(o w <br /> Property Owners Mar ing Address Lot Num utn r <br /> 7o3J G1 r.4 / AUC AJ <br /> City.state Zip Code Phone Number sublivisionName:or CSM Number <br /> (rO O tel Y/ c e,ter 1 Y5- ( 6 <br /> II.Type of Building: (check one) ❑City <br /> S1 or 2 Family Dwelling-No.of Bedrooms: 3 O Village <br /> Public/Comimcrcial(describe use):_ Town of <br /> ❑State-Owned &!l)/G/s <br /> Nearest Road <br /> VOW LOO <br /> Pas ax s O OQ <br /> III.Ty e of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. New 2. Replacement 3. Replacement of 4. 5. 6. Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number ssued <br /> E3 Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> DkNon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Welland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass O Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.DispersaYrreatment Area Information: <br /> ign ow 8p 2.Da Area 3.Dispers Area 4.So r Application 5.Percolation gate 6.System Elevation 7.Find Gmde <br /> Rcquhed Proposed Rate(Gdsldayrsq.ft) (Min./mch) Elevation <br /> vso / /3 5'X `7 ,.r , L <br /> VII.Tank Capacity in Total R of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Bxisting trete strutted <br /> Ta/nkyss Tanks <br /> .SS ❑ ❑ ❑ ❑ <br /> C. <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumbers None not Plumber's Signature no sumps): MPWRSNo. Business Phone Number <br /> W hd c6/6//P? Gr) X769/ <br /> Plumbers Address(Street,City,State,Zip ode) <br /> A6 S/ _5_1'r 7.-PL- <br /> IX.County/Department Use Only <br /> Disapproved Sanitery Permit K(Includes undwater Date Issued Issuin em Si o stamps) <br /> Approved ❑Owner Given initial Adverse surcharge Fel �� <br /> Determination V U (0 <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />