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VisconsinSee <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> reverse side for instructions for completing this application PO Box 7302 <br /> Department of Commerce 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 /> 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. state owned. <br /> Count State Pe it Number 13 Check irevision to previous application State Plan I.D.Number A/A <br /> I.Application Information-Please Print all Information V �E Location: <br /> Property Owner Name <br /> mProperty Location 2 <br /> Property Owners Mailing Address 3 <br /> 1/4 1/4 S T40,N,44(or)W <br /> Lot Number oyer <br /> 1 G.L. I <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> �3wmm 01 <br /> cs ��s- 81 <br /> II.Type of Building: (check one) V 17 _ I <br /> ❑city <br /> I or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): Town of <br /> ❑ State-Owned 7 Qn_ir <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road L <br /> A) 1. ❑New System 2. Replacement 3. ❑Replacement of 4. ❑Addition to Par el Tax N mber(s) <br /> S stem Tank OnlyExistingSystem B) Permit Number Date Issue <br /> ❑A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System: (Check all that apply) <br /> )imIon-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 /> 3 O Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) 1 `• Elevationg4.s- <br /> (Doo (,,00 . S •_ _ 9419 <br /> VI.TankCapacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic 4S.f7 <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume res onsibili for installation of the POWTS shown on the attachedplans. <br /> Plumber's Name(print) Plumber's Signa (n mps): MP/MPRS No. Business Phone Number <br /> c!}Rt nK�rls $S <br /> lumbe•'� edd.P..lCtreet.Citvtate,Zip ode) <br /> Z-�7�o 3-S 1ASt€iz W 1. 3 <br /> VIII. ounty/Department Use Only <br /> .,a� ❑Disapproved Sanitary Permit Fee udes Gnronundwater 7i/O <br /> Issuing, ge SignaFo <br /> sed ❑Owner Given Initial Adverse Surcharge Fee) 2 W r <br /> Determination W <br /> IX.Conditions of Approval/Reasons for Disapproval: _7' <br /> SBD-6398 R07/00 <br />