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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 /> VisC�ns]» 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 1 inches in size. <br /> County Se�Sanjt7�it Number ❑the iFrevi io�[o previous application S[at�Plan sg3a <br /> I. Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location �) <br /> 1/4 X1/4,S (�,N,&� <br /> Property Owner's Mailmg Address Lot Number Block Number <br /> c.s m v/R <br /> City,State / Zip Code Phone Number Subdivision Name or CSM Number <br /> p d <br /> s o <br /> 11.Type of"Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑(Village <br /> Public/Commercial(describe use):_S,{/�tr//s1Q6jc�C t✓ze,6 /�'/Erf z � /�I1yT�jZ 1"Town of ��� 3 <br /> ❑ State-Owned <br /> Nearest Road <br /> E <br /> Y�- D arc I Tax ber( —/6� <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. P New 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑Addition to <br /> B) <br /> System System Tank Only Existing System <br /> 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 Welland- <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(Gals./day/sq.ft.) '(Min./inch) Elevation <br /> .?B7 . /, L 7 o/ <br /> VII.Tank Capacity in Total k of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> ❑ ❑ ❑ ❑ <br /> VIII. Responsibility Statement <br /> I,the undersigned,assume responsibility for=(nostam <br /> shown on the attached plans. <br /> Plumber's Name(print) Plumber' MP/MPRs No. Business Phone Number <br /> Plumbers Address(Street,City,State,Zip Codc) [I/Q1 ? <br /> 211 c E>v rr �� <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent Signature o stat.ps) <br /> Approved ❑Owner Given Initial Adverse SurchargI e F;e�� <br /> Determination c G-D <br /> D <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />