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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 /> `*soOnsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 CC�� ,, <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not �J <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. d <br /> Coun State Sanitary PerqutN7ber r ❑Ch if rev' ion to previous Application State Plan I.D.Number <br /> I.Application Information-Please Print al Information " !J Location: <br /> Property Owner Name Property Location 77 <br /> `o C f(tet 1/4/(1 JI/4,S T�,PN,R/Z(or W <br /> Properly Owner's Mailing A dress Lot Number Block Number <br /> o? 3 7 F2 e <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> �II�..r Type of Building: (check one) ❑City <br /> PL 1 or 2 Family Dwelling-No.of Bedrooms: sZ ❑Village <br /> ❑Public/Commercial(describe use):_ P4own of <br /> ❑State-OwnedLk /v/-Cis <br /> Nearest oad <br /> V-- C—. <br /> Parcel Tax0Nrynber(,S,l / o O <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) be �� <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 Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> $,cion-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 /> VII.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 /> 00 /DO U a rwCs c v 0 11 <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.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 Signatureno stamps): MP/MPRS No. Business Phone Number <br /> lumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issum A! nt S�i to o ps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee)aQ('� 001 41 /eZL) <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R 07/00) <br />