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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 /> Visconsin 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 paler not less than 8-1/2 x 1 I inches in size. <br /> County State S Permit Number 91CAeck if revisi n to prev us application State Plan 1.D.Number <br /> I. Application Information-Please Print all Information Location: <br /> Property Ow er Name / J Property Location <br /> Ow <br /> R/9 <br /> MQ'-m rh e r f C �7 . 'Qr 1/4 I/4,S;?&y6,N,R/9(or)W <br /> Property Owner's tf ailing Address Lot Number Block Number <br /> 76 N 7�Qu C 4i?-. /Cy- ,Z43-1-/.7-/P A7? <br /> City,State / Zip Code Phone Number Subdivision Name or CSM Number <br /> �se <br /> II. Type of Building: (check one) ❑City <br /> A 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use):_ B Town of <br /> ❑ State-Owned <br /> Nearest Road /J <br /> / q" l o L �/,�J /J Fer( <br /> 7i.0 2. �/'i ( '�e`., Parcel Tax Number(s)p <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) 666 <br /> A) 1. New 2. ❑ Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <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 ❑ 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: 9 6�v r 6 <br /> 1. Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Re wired Pro osed Rate(Gals./day/sq.ft.) (Min./inch) Gra,,PCj Elevation <br /> 20 C) Lison CO .� a � _ � 4,, 6 t 9/., ' <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 /> Tanks Tanks CIOr G <br /> g] ❑ ❑ ❑ ❑ <br /> VIII. Responsibility Statement <br /> 1,the undersigned,assume responsibility for installatiorKf the POWTS shown on the attached plans. <br /> Plumber's ame(print) Plu ber' Sign ure( stamps): /MPRS No. Business Phone Number <br /> ,ii- S�tk-j- ��, 3Z v 7 6 7)d-- v7c a,-a7 <br /> Plumber's r <br /> dress(Street,City,State,Zip Code) <br /> 6 � b)r l/V 4 L.f G � <br /> IX. County/Department Use Only <br /> 2( ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issui nt Signatur o stamps) <br /> t2 Approved ❑Owner Given Initial Adverse Surcharge Fee) y� <br /> Determination 4 2,51J'/ ja �D 0 <br /> X. Conditions of Approval/Reasons for Disapproval: <br /> L <br /> JUL 272004 <br /> COUNTY <br /> SBD-6398(R.07/00) ZONING <br />