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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 /> Visi6onsin <br /> 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 of commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned.) <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. <br /> County,QState Sanitary Permit Number ❑Check ff revision previous application State Plan I.D.Number <br /> /J �r/U e 74 ,) l� <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner N e Property Location <br /> // V6 /.S — <br /> it-/ L"G(/ / 1/4 1/4,S42T N,R E(or W <br /> Property Owner s Mailing Address Lot Number Block Number (U <br /> s 5;,/ o �l — 01 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> S.c,f w 5 ya (his )`/�'�-5s3 �i^�r9svre s/,14114 7`01 <br /> II.Type of Building: (check one) ❑City <br /> I or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> Public/Commercial(describe use):_ .— Town of <br /> ❑ State-Owned kScl,� <br /> Nearest Road /^� <br /> Parcel Tax Nu a s) 70 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. w 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) <br /> 13 Permit Number Date Issued <br /> A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> Ton-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 /> ,L/ rTTanks Tanks <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 Signature(no stamps): MP/MPRS No. Business Phone Number <br /> &Awe & z �,� Sys-�z� �C <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued IssuingAgOqnature stamps) <br /> Ad Approved ❑Owner Given Initial Adverse I Surcharge Fee) <br /> Determination K7 <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />