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a o g� <br /> Sanitary Permit Application Safety&Buildings Division <br /> \ In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> ♦visconsinSee reverse side for instructions for completing this application PO Box 7302 <br /> Department 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 lete lans to the coup co onl or the s stem,on paper not less than 8-1/2 x 11 inches in size. <br /> County State5,anitw Permit Number h4if i t vious application State Plan I.D.Number <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> S%vr, <br /> 1/4 1/4,S T N, or W <br /> Property Owners Mailing Address Lot Number �v- 4� <br /> 550 t�G' Z <br /> 2 .� <br /> City,State • Zip Code Phone Number Subdivision Name or CSM Number <br /> IS )Q47- <br /> 11.Type of Building: (check one) ❑City <br /> !" 1 or 2 Family Dwelling-No.of Bedrooms: Z- Village <br /> ❑ Public/Commercial(describe use): own of / ON <br /> ❑ State-Owned AV <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> ^', Q <br /> A) 1. New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel ax Number(s) <br /> SystemTank Onl Existin S stem <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> �I,V/.Type of POWT System: (Check all that apply) <br /> _FNon-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.ft.) (Min./inch) Elevation <br /> 9g-8 g 7 <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> NewLExisting crete structed <br /> Tankslea � �� ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <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 s ps): MP/MPRS No. Business Phone Number <br /> ctlMgo Plvrls � 2Z5$S 1 7/S- 8r'o6- q 157 <br /> lumber's Address(Street,City,State,Zip ode) <br /> Z.77&0 Nw *S In�'SS7i=2, I.tll . S�f$9� <br /> VIII.County/Department Ifse Only <br /> ❑Disapproved Sanitary Perm' Fee(Includes Groundwater Date I s ed AIssuing ge Sigrmpproved ❑Owner Given Initial Adverse Surcharge FeB � <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />