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Sanitary Permit Application Safety&Buildings Division <br /> S In accord with Comm 83.2 1,Wis.Adm. Code PO 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application 153707-7302 <br /> Box 7302 <br /> isconsin Personal information you provide may be used for secondary purposes Madison,WI 5 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state o ed. <br /> Attach complete plans to the county copy only)for the system,on paper not less than 8-1/2 x 1 I inches in size. ti <br /> County State Sanit Permit Number ❑Check if revision to rev'ous application State lar J.D.NurjLber (75— <br /> S— 10 , t <br /> I.A cation Information-Please Print all Information Location: <br /> Property Owner Name P/ e¢y Location <br /> Gp'a 'r C�1/4-S�1/4 S T ,N,R o <br /> Property Ownees Mailing Address Lot Number Block Number <br /> MS 45A- AJ. <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> DS cjolA Wl - 1 S4D20 19, SS- oq 8&965 <br /> II.Type of Building: (check one) ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: 2 ❑Village <br /> ❑ Public/Commercial(describe use): J�ICTown of <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road /wTOP <br /> A) 1. 1ANew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parc 60 <br /> System Tank OnI3 ExistS stem �J�j <br /> B) 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 Vmound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-erade ❑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 /> 300 300 1 1-0 ,t_ 102— Ho 10.0 <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 /> V0 g00 SKAVI ❑ ❑ ❑ ❑ <br /> Soo — 400 I " �q ❑ ❑ 1 ❑ 13 <br /> VII.Responsibility Statement <br /> I,the undersigned,assume res on ibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature( s s): MP/MPRS No. Business Phone Number <br /> LMgP pWjJ ' 2zS'SSl IS S(a6- 4157 <br /> PI bet's Address(Street,City,State,Zip Cc(le) <br /> 3S EBs`r LJ�. 54883 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Is g Agent Si ature(No stamps) <br /> Approved ❑Owner Given Initial AdverseSurcharge <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />