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Sanitary Permit Application Safety&Buildings Div n <br /> `�' In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington e. <br /> seonsinSee reverse side for instructions for completing this application PO Box <br /> Department of commerce Personal information you provide may be used for secondary purposes Madison,WI 53707- <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county t <br /> state ow <br /> Attach com tete plans to the county copy only)for th system,on paper not less than 8-1/2 x 11 inches in size. <br /> County State Sanit PrmutN if rev'siat 3reviouN application State Plan 1.D.Number <br /> I.AppTication Information-Please Printlaff In ormat on Location: <br /> Property Owner Name 7 Property Location //��__ A,r--0 <br /> 1/4 tV 1/4,S/�T` ,N,RICE or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> -0- Box `Z7 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> WYOM10(4 " Mo 55Dg2 4siz )4z- iwo <br /> II.Type of Building: (check one) ❑City <br /> ❑ I or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> Public/Commercial(describe use): Jf- � E3rz J}o MV_ XTown of <br /> ❑ State-Owned OA"N/D <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road C-0- U . <br /> A) 1. ew System 2. 13Replacement 3. ❑ Replacement of 4. El Addition to Parcel Tax Numbe ) <br /> System Tank Only ExistingSystem Q20 % D2 <br /> B) <br /> I Permit Number Date issued <br /> ❑A SanitaryPermit was reviousl issued <br /> IV.Type of POWT System: (Check all that apply) <br /> on-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 /> I.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 /> 1.S00 2143 Z soz . 6 9� 3 f7:5 <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> G 3l3� 31.3L ❑ ❑ ❑ ❑ <br /> G /Oov /vfla / ❑ 13 ❑ <br /> VII.Responsibility Statement <br /> 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> cs{A,2o .✓ AW04-= ?2585/� 71s- <br /> Plumbers Address(Street,City State,Zip Code) <br /> 2.7760 35P S4$133 <br /> VIII.County/Department Use Only <br /> ❑Disapproved SanitaryPermit Fee includes Groundwater Date Issued Issui Agent Si Epproviature(No stampsed ❑Owner Given Initial Adverse Surcharge Fee) ��� nl�� ' <br /> Determination / <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />