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� ( �, <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> `�seonsin See reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for secondary Madison,WI 53707-7302 <br /> Department or Commerce Y P Y dart Purposes Submit completed form to court not t 1\ <br /> ' [Privacy Law,s. 15.04(1)(m)] ( P county�if � 1 <br /> state owned. <br /> Attach complete plans to the county copy only)for the system,jonr not less than 8-1/2 x l l inches in size. <br /> County State Sanitary Permit Number O C k if revi us applicati State Plan I.D.Number <br /> &t rn,e7t 1 <br /> I.Application Information-Please Print allInformation Location: <br /> Property Owner Name Property Location <br /> Lala° #e m es .4-Ine- <br /> !W 1/4NW 1/4S36TND,N RITE(orito <br /> Property Owner's Marling Address Lot Number Bloch Number <br /> SOS,,b 13e-YsA Ave j <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Rush el'it � 53-6 Lq 3,�'o erg 3148 V. 1 P '212 <br /> Il.Type of Building: (check one) ❑city <br /> 21. 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): -.1 el Town of <br /> ❑ State-Owned LAO C-k soh <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) N712' <br /> �a* t Road /� / <br /> 1'� '1Cf <br /> A) 1. OfNew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> system Tank Only Existing System O(,X,—4 J.3/o --0 S'— V0 <br /> B) Permit Number Date Issued <br /> El SanitaryPermit was previouslyissued <br /> IV.Type of POWT System:(Check all that apply) <br /> Il(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 Arca 4.Soil Application 5.Percolation Rete 6.System Elevation 7.Final Grade <br /> 00 <br /> Required Proposed Rate(GalsJday/aq.ft.) (Min./inch) Elevation <br /> &e o /o OI> r 5� 1 C7Z/,S 17,S' <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> 5 el 1/ /000 /AJD NO I-w esL,0 ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume res Ibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Siva (no a ps): MP/MPRS No. Business Phone Number <br /> we,d fl)k KS Xi'q It-), 1��Gl a.2 7V y/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Yo 2 <br /> VIII.County/Department Use Only <br /> ❑DisapprovedSanitaryPenni F (Includes Gmugdwater Date Is Issuing t Si ) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee x7� VwVI <br /> Detcrmination (SCJ r <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 807/00 <br />