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Sanitary Permit Application <br /> In accord with Comm 83,21,Wis.Adm. Code Safety&Buildings D' n <br /> Arscon,,!#n See reverse side for instructions for completing this application 201 W Washingt v <br /> Department or coerce Personal information you Provide may be used for seconds 15 70 2 <br /> [Privacy Law,s. 15.04 I m n purposes I Madison,WI 5370 <br /> ( )( )) (Submit completed form to corm n t <br /> Attach com lete tans to the coup co onl ) the s stem,on a er of less than 8-1/2 x 1 I inches in size. state o ) <br /> County State S "t Permit Number <br /> heck_i[Levision to previous pplication State Plan 1.D.Number <br /> I.A IlcatlOn Information-Please tint all Information f�f <br /> Property Owner Name Location: <br /> I e Property Location <br /> Property Owner's Mailing �;er Address 1/4 I/4,S <br /> Lot Number T Bl or W <br /> `J T Block Number <br /> City,State Zip Code Phone Number Jr. 3P15 of <br /> Subdivision Name or CSM Number <br /> e. /Al 5 fi37S' (76 <br /> II.Type of Bu Idling: ) q 72 <br /> g: (check one) <br /> l@ I or 2 Family Dwelling-No.of Bedrooms: 2 ❑City <br /> ❑ Public/Commercial(describe use): ❑Village <br /> ❑ State-Ownedjip own of5 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) nearest Road 41`� <br /> ±B) <br /> ❑New System 2. Replacement 3. C Replacement of 4. N p rQ <br /> S stem ❑Addition to Parcel T�nu�r(s) Q <br /> Tank Only Existin S stem Da <br /> Sanita Permit was reviousl issued Permit Number <br /> Date issued <br /> IV.Type of POWT System: ((-:heck all that apply) <br /> %Non-pressurized In-ground ED Mound❑ Pressurized In-ground ❑Sand Filter C Constructed Wetland <br /> ElAt- de ❑ Holding Tank ❑Single Pass ❑Drip Line <br /> V.Dis ersal/Treatment Area Information: ❑Aerobic Treatment Unit ❑Recirculatin¢ C Other <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area <br /> Required 4 <br /> 9 .Soil Application 5.Percolation Rate <br /> Proposed Rate(Gals./da /s 6.System Elevation i.Final Grade <br /> /l Y 4 t1.) (Min./inch) <br /> yZ� L l�Jz Elevation <br /> VI.Tank r 7 �(y P75.0 <br /> Capacity in Total 4 of Manufacturer <br /> Information Gallons Gallons Tanks Prefab Site Steel Fiber- Plastic <br /> New Existing I Con- Con- i glass <br /> Tanks Tanks crete structed <br /> 5 L 600 Li ❑ i ❑ ❑ <br /> l O L I j <br /> VII.Responsibility Statement <br /> 1,the undersi ed,assume res onsibili for installation of the POWTS shown on the attached tans. <br /> Plumber's Name(print) Plumber's Signature(no scams <br /> G �N . P ) MP/MPRs No. <br /> I Mint+ �I y � Business Pho/ne Number <br /> umber's Add re//ss(Sneet,City,State,Zip Codej 22� ��� 1/5'- 106— S <br /> VIII.County/Depart ent Use Only / <br /> ❑Disapproved Sanita Permit <br /> pproved ❑Owner Given Initial.Adverse rY tlnclude�Groundwatcr Date is ed " <br /> Surcharge I Issut n[S n o tam -1 <br /> Determination <br /> IAC. Conditions of Approval/Reasons for Disapproval: <br /> SBD-639,,R07,'00 <br />