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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> 'WisconsinDepartment 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 /> state owned. <br /> Attach com Tete plans to the coup co only) s for the m,on paper not less than 8-1/2 x 11 inches in size. <br /> Co y ,. State Sanitary P u Check' re ision�tyvi us k <br /> p ation State Pan I.D.Number <br /> -4 <br /> I.Application Information-Please Print Info ation Location: <br /> Property Owner Name Property Location �j J <br /> `� 1/4 1/4,&;YT3e ,N, B or <br /> Property Owner's Majlfni Address Lot Number Block Number <br /> City)Sjte Zip Code Phone Number Su4divWmet-Name or CSM Number <br /> II.Type of Building: (check one) O City <br /> til'` I or 2 Family Dwelling-No.of Bedrooms: L12 ❑Village <br /> ❑ Public/Commercial(describe use): 94Town q� <br /> ❑ State-Owned /e/ 5l <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Near st Roatll�m K <br /> A) 1. ❑New System 2. Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax N////umber(s) <br /> System Tank Only Existing System ';2 a <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued <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: <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.it.) (Min./inch) Elevation <br /> o <br /> !�C> 3 y <br /> a O f > 7 d ,. <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 /> y�� `�aC� O ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume res onsibili 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 /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Is ed Issuing A t rgna CN ) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination �Z) <br /> Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />