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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 /> ��scoisiinSee reverse side for instructions for completing this application PO Box 7302 <br /> Department of t ommerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> [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 11 inches in size. <br /> County n State Sani Pe tuber ❑Ch if reyision 4MFCvis application State Plan 1.D.Number <br /> FC Ot <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name <br /> Prpperty Location vn <br /> �Atl � 14LE410 '1/4,S T�.N, E o O <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 29055' 72AZVU4 10,J01. _%)-)-)q 9.58 A wzEs <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 'PA*1 a W t- $4$3o _ <br /> II.Type of Building: (check one) ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: I� ❑Village <br /> ❑ Public/Commercial(describe use): Town of ►1u��0 <br /> ❑ State-Owned 04 <br /> WAND <br /> Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road PIMLAJ <br /> HB) <br /> 1. ❑New System 2. Replacement 3. ❑Replacement of 4. ❑Addition to Pa Tax N er(s <br /> S stem Tank Only ExistingS stem */ zb <br /> ^, �� <br /> Sanitary Permit was previouslyPermit Number Date Issued <br /> , issued WCC <br /> V.Type of POWT System: (Check all that apply) O <br /> ,WNon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <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 /> 300 429 432, 3 U-4 q9 , o <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 /> Iwo — 1000 1 pokv)'Erw ❑ El El1-1 <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature o ps): MP/MPRS No. Business Phone Number <br /> s - gSl K= - tS <br /> Plumber's Address(Street,City,State,Zip C de) <br /> 7Go <br /> VIII.County/Department se Only <br /> ❑Disapproved Sanitary Permit Fe(Includes Groundwater Date Issued Issui gen gna stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee `�� _ <br /> Determination t! /✓- 8 /S- 114 <br /> tom <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />