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4�?7(j, p S9e3, <br /> Sanitary Permit Application Safety&Buildwaawisio, <br /> Vh5cohSilin <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.WashZX-130 <br /> w <br /> See reverse side for instructions for completing this application P30Personal information you provide may be used for seconds Madison,WI ' <br /> Department of Commerce Y P Y secondary purposes[Privacy Law,s. 15.04(1)(m)] (Submit completed form to co,f nc <br /> stile ed. <br /> Attach complete plans to the countyco only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Pe it Number ❑Check}f revision to previous application State Plan 1.D.Number O (}' <br /> I.A ication Information-Please Print all Inf r ation Location: ` ` <br /> Property Owner Name Property Location �/ // <br /> I& 1/4 1/4,S Y T N, f7E or <br /> Property Owners Mailing Address Lot Number Block Number <br /> 21x8 OfF.LN/l o R� <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> l5 > - s <br /> II Type of Building: (check one) ❑City <br /> I or 2 Family Dwelling-No.of Bedrooms: 2— ❑}tillage <br /> ❑ Public/Commercial(describe use): own of <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. —,jiLNew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank OnlyExistingSystem 05 /0 <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 --Jgmound ❑ 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(GalsJday/sq.ft.) (Min./inch) Elevation <br /> D /'0 /0/ . (0 /95 <br /> VI.Tank Capacity inTotal I #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> ❑ ❑ ❑ ❑ <br /> L44 <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached 21ans. <br /> Plumbers Name(print) Plumbers Signature(no stamps): MP/MPRS No. Business Phone Number <br /> l_ommw v� 22585/ <br /> P'lumbees Address(Street,City State,Zip Code) <br /> 7_3 tiv 35- Wg'a W1. 54893 <br /> VIII. County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Ag nt Srur mps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination 50" NO <br /> IY.Conditions of Approval/Reasons for Disapproval: - -S - <br /> SFP 1 2001 <br /> ev <br /> SBD-6398 R07/00 <br /> `L�oNvvc-' <br />