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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 /> `�sevnSin See reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department or Commerce y P y dary PtuP Submit completed form to county f <br /> [Privacy Law,a. 15.04(1)(m)) ( P ty'if <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 Sanitary Permit Number ❑Check if revision to previous application State Plan I.D.Number <br /> I.Application Information-Please Print an Information Location: <br /> Pmkcrty Owner Name PropeertyL/�'ation /J <br /> F W I/4'V l/4 4 T3 SNR/ W <br /> Property Ownds Mailing as _ ,-, n <br /> // Lot Number Block Nu <br /> Q(_/� m <br /> City, to ZiP Code Phone Number Subdivision Name or CSM Number <br /> 1 115 3a7-s:51P <br /> I.Tyilding:pe of Bu (check one) / ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: `t Village �� n <br /> Pablic <br /> lCommereiall(describe use): Town of <br /> ❑ State-Owned <br /> III.Type of P : (Check only one box on line A. Check box on line B if applicable) Ne at Road. <br /> A) L X N System Replacement 3. ❑Replacement of 4. ❑Addition to Parte Tax Numbers <br /> S stem Tank Onl ExistingS stem b — 17 3'Q <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System:(Check all that apply) <br /> ❑Non-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 Proposal Rate(Gals./day/sq.n.) (Min./inch) Elevation <br /> Wtv 6mq6 .7 991510 ,ao <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons i Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> (R.4�0t o � (�i escr ❑ ❑ ❑ ❑ <br /> 756 1 1 `)5) GtJTes ❑ ❑ ❑ ❑ ❑ <br /> VII.114sponsibility Statement <br /> I,the undersigned,assume responsh lity for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) I lumbees Signa (n ): MP/MPRS No. Business Phone Number <br /> N els ass as 9�s-� -�&0� <br /> Plumber's Addross(S City,State,Zip C )�— L�ks 9 <br /> led <br /> VIII.County/Departifient Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Iss <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) ^� p8 to p s <br /> Determination �` `G <br /> IX.Conditions of Approval/Reasons for Disapprov <br /> e U�Sib � <br /> SBD-6398 R07/00 <br />