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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 /> ` SCOIfSin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of commerce (Submit completed form to county if not <br /> [Privacy Law,s. 15.04(i)(m)] 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 Stat��ajar4a 't Num ❑CheioIf revision o previous application State Plan I.D.Number <br /> I.A ication Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> 3 1/4 1/4,S37T r_,N,R or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 21ld Ytdi N _ L 3 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Ah , 1S ) - JkOlrgSEs <br /> II.Type of Building: (check one) ❑City <br /> 111 or 2 Family Dwelling-No.of Bedrooms: 2 12 Village <br /> yAo[own of <br /> ❑ Public/Commercial(describe use): nn <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) I. ew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel TN b s) Nu <br /> S stem Tank Only Existing System 1 <br /> 04- 00 <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was previously issued <br /> IV Type of POWT System: (Check all that apply) <br /> on-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 /> RequiredProposed Rate(Galslday/sq.ft.) (Min./inch) Elevation <br /> 3br *Zq 437, . 7 1 0 - q4.5 17 <br /> VI.Tank Capacity in Total I #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks I Tanks I Ar <br /> /� lox5kAL1/ ❑ ❑ ❑ ❑ <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(no stamps): MP/MPRS No. Business Phone Number <br /> Gfft�,2b ,✓ X2 15/ S- &4410 <br /> umbers Address(Street,City State,Zip Co e) <br /> 2-?7� 3S WE�s WI- S48q 3 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Perm' ,Fee(Includes Groundwater Date I sued � [ssui gen gna o stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fea4( wpm`� 1 <br /> Determination �(P lJ iJ(J <br /> IX. onditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />