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Sanitary Permit Appli jcOMPUTE SCAN^,' Safety&Buildings Division <br /> m <br /> In accord with Com83.21,Wis.Adm. Code NED201 W.Washington Ave. <br /> �viseonsin See 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 ifnot <br /> state owned. <br /> Attach complete lana to the coup co only)for the system,on a not less than 8-1/2 x l l inches in size. / h <br /> County Stare S P Numb cek i('�tevis ont prev' application State Plan .D Number lJ ) <br /> p� (p <br /> I.A cation Information-Please PrI t a I formation Location: <br /> Property Owner Name Property Location Q <br /> Property Owner's Mailing A Lot Nlumber 1/4 S1 T N or W <br /> Ci grate 1 A . S- �- peCES <br /> City, Zip Code Pho a Number Subdivision Name or M Number <br /> N Seto ,Z 29- 113 . Ul P. 2g3 <br /> II.Type of Building: (check one) ❑city <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 3 AD}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 DID _K <br /> A) 1. ")gNew System 1 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parc N s <br /> System Tank Only Existing System <br /> B) Permit Number Date lasued <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 Ares 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Re aired Proposed Rate(GalsJday/sq.ft.) (Min./inch) Elevation <br /> � 1.0 �g S1100. 6 <br /> VI.Tank Capacity inTotal #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks <br /> Tanks <br /> ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> PI es Name(print) Plumber's Signature( s ps): MP/MPRS No. Business Phone Number <br /> �s 2zs$s� �s s <br /> PjAmbees Address(Street,City,State,Zip ) <br /> --( 4WSsM WI. 3 <br /> VIII.County/Department Vse Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Is ed Issuing g Si ps) <br /> 4ppmved 11Owner Given Initial Adverse Surcharge Fee) ^/ <br /> Determination SJ (o 4 <br /> IX.Conditions of Approval Reasons for Disapproval: <br /> SBD-6398 R07M <br />