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Safety&Buildings Di <br /> Sanitary Permit Application 201 W.Washingto A <br /> ASC"OnSin <br /> In accord with Comm 83.21,Wis.Adm. Code PO Box 2 <br /> See reverse side for instructions for completing this application Madison,WI 53707 <br /> Personal information.you provide may be used for secondary purposes (Submit completed form to county of <br /> Department of Commerce LPrivacy Law,s. 15.04(1)(m)) state O <br /> Attach Com Tete tans to the coun co onl )for s stem,on a er n less than 8-1/2 x 11 inches in size. <br /> AIA- <br /> County State Sanitary. 't u r ❑ if re�{iFio to rev' us a lication State Plan[.D.Number <br /> SDI <br /> VIIIIIIM <br /> I.A ication Information-Please Print all Information �� Location: <br /> Property Location <br /> Property Owner Name ,{0 ''^^ <br /> 1!4 1/4,S.3 T`( ,N, (AW <br /> IIIII I Q Lot Number <br /> Property Owners Mailing Address <br /> - Zi Code Phone Number Subdivision Name or CSM Number <br /> City,State P <br /> N S 10 t ,4a�_ 99 q e /.k• <br /> AM proz ❑City <br /> II.Type of Building: check one) C3Village <br /> 1 or 2 Family Dwelling-No.of Bedrooms: - Town of <br /> Public/Commercial(describe use): <br /> ❑ State-Owned Meares[Road <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) p <br /> A) I",�INew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numb r(s 62 <br /> O� scr <br /> S stem Tank Only Existing System <br /> Permit Number Date Issued <br /> B) <br /> ❑A Sanita Permit was reviousl issued <br /> V.Type of POWT System: (Check all that apply) ❑ Sand Filter ❑Constructed Wetland <br /> Non-pressurized In-ground ❑Mound <br /> ❑Pressurized In-ground ❑ Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At- de ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dis ersaYrreatment Area Information: 7.Final <br /> I.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation Elevation rade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) <br /> �� �4� �- q4- 9 s 6_3 -I-- <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Gallons Gallons Tanks Con- Con- glass <br /> In <br /> New Existing Crete strutted <br /> Tanks Tanks <br /> ❑ ❑ ❑ ❑ <br /> [boo — 1)of) � <br /> Cl ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume res onsibili for installation of the POWTS shown on the attached plans. Business 0I _Phone Number <br /> Plumber's Name(print) Plumber's Signature(no stamps): MP/MPRS No. <br /> Plumber's Address(Street,City State,Zip Cc e) <br /> 2.7160 3S W£�sra� uli. 5'4$93 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(I eludes Groundwater Date ISS ed Issuing Age t Signa re ps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) �1P{ A Q � Ol <br /> Determination �J <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 8071100 <br />