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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> �� See reverse side for instructions for completing this application PO Box 7302 <br /> `vsconsin personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned. <br /> Attach complete plans to the county copy only)f r the system,on paper not less than 8-1/2 x 11 inches in size. <br /> CountyState Sanitary emit Number Check i revision to pre us application State Plan 1.D.Number <br /> Afvrn <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location C <br /> / �cl• <br /> Q I17t» I*YOT SD/7 1/4 5E/4 S YS-T 37,N,R/46E or <br /> Property <br /> Owneru <br /> 's Mailing Address of Nmber Block Number <br /> 7 <br /> 2 a'er �(/a lkr AOL/ <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> J�? <br /> II.Type of Building: (check one) ❑city <br /> 91 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): NTown 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�a�d 41 r 'Ot2�� <br /> A) 1. ❑New System 2. Of Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Only Existin System 0 .1g — J33:f"- a8 /Da <br /> B) Permit Number Date Issued <br /> 13A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> PNon-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) 7f 7-Z Elevation <br /> 3e>0 ZS o z 7%73 703 9� <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 /> 93„ 0 / GtJ:csc f IT ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersijzned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(pri Plum er's Sign re tamps): MP/MPRS No. Business Phone Number <br /> goer � ulcer /Sen <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 3S72- 115A S �- Fr�� ert'c w ` Sy837 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing gent Signature(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee)__O) <br /> 75 ^ �� JDT <br /> Determination J (� V tw <br /> matgi <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> ----------------- <br /> SBD-6398 R07/00 <br />