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Sanitary Permit Application Safety 8a 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 ystem,on paper not less than 8-1/2 x 11 inches in size. <br /> Cour State Sant Permit Number 11Ch k'f revigion to previou pplication State Plan L D.Number <br /> I.Application Information-Please Print all Informati n Location: <br /> Property Owner Name / Property Location '-77 <br /> Z- 4 C V � C^) G i 1/4 �1/4,S33 T.? ,N,R/Z(or <br /> Property UwWs Mailing Address Lot Number Block Number <br /> 6� c Aa <br /> City,State / Zip Code LPhone Number Su ' ' ' or CSM Number <br /> r tt1� sy8 3 ) V s <br /> II.Type of Building: (check one) ❑city <br /> l or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ _ I town of <br /> / <br /> ❑State-Owned )) <br /> Nearest Road. <br /> P cel A ax Numbe 9 <br /> III.Type of P rmit: (Check only one box on line A. Check box on line B if applicable) O£a <br /> A) 1, ew 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 /> Ion-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.DispersalPlYeatment 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 /> -500 <br /> 7;7, s <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 stmcted <br /> Tanks I Tanks <br /> Odd 00 C) IVO/'we-5'C D ❑ ❑ ❑ ❑ 0� <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) �- <br /> Plumber's Signature no slam s): MP/MPRS No. Business Phone Number <br /> 771 - ;7s P61 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Is g Ag Signature(No stamps) <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee) / <br /> Determination if LOU• ��-°Z-7 �a <br /> X.Conditions of Approval/Reasons for Disapproval: ILI <br /> aer 2 3 <br /> BURNS <br /> SBD-6398(R.07/00) <br /> �NIN NTY <br />