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Safety Buildings Division <br /> Sanitary Permit Application 201 W.Washington Ave. <br /> In accord with Comm 83.21,Wis.Adm. Code PO Box 7302 <br /> See reverse side for instructions for completing this application Madison,W1:0 <br /> 53707-7302 <br /> `�SCOIfSin Personal information you provide may be used for secondary purposes (Submit completed form to county if not <br /> Department of commerce [Privacy Law,s. 15.04(1)(m)l state owned. <br /> Attach com Tete Tans to the coon co only)forthe system,on er not less than 8-1/2 x 11 inches in size. <br /> County State Sanitary ermit Number heck I�revision top ious application State Plan I.D.Number <br /> 02 <br /> I.Application Information-Please Print all Information Location: <br /> Property Location <br /> Property Owner Name <br /> 5Wl 0� � 1/4 1/4,S�T ,N R16E or W <br /> Lot Number Block Number <br /> Property Owner's Mailing Address <br /> Zi Code Phone Number Subdivision Name or CSM Number <br /> City,State P <br /> OM W4 M Z 12 Z-�6�� <br /> ❑city <br /> II. ype of Building: (check one) ❑village <br /> 1 or 2 Family Dwelling-No.of Bedro s: "I"RR/l own of 0� _!Vr� <br /> Public/Commercial(describe use): <br /> ❑ State-Owned Nearest Road CO- U <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) W <br /> Parcel Tax Number(s) <br /> LB) <br /> 1. [�}Vew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Pa <br /> / System Tank Onl ExistingSystem <br /> Permit Number Date Issued <br /> ❑A Sanitary Permit was reviously issued <br /> IV.Type of POWT System:(Check all that apply) ❑Mound El Sand Filter ❑Constructed Wetland <br /> Non-pressurized In-ground ❑Sin le Pass ❑Drip Line <br /> Pressurized In-ground ❑Holding Tank g <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dis ersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation Elevationrade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) <br /> 24-0ti '7 - 95. -?. <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> ass <br /> Gallons Gallons Tanks Con- Con- g <br /> Information New Existing crete structed <br /> Tanks Tanks ❑ ❑ ❑ ❑ <br /> 7,Spo 0 Zlr✓ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume res onsibili for installation of the POWTS shown MPS RS Nhe o. Business <br /> plans. Business Phone Number <br /> Plumber's Name(print) Plumber's Signature(n s ): <br /> 1 c H Aec� f�lu0ff — 2 4 I S— �— <br /> P mber's Address(Street,City,State,Zip Co ) <br /> 35 <br /> VIII.County/Department tJse CInly <br /> :Determination Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Age Sign re ps) <br /> Approved Owner Given Initial Adverse SurchargeFee) /�{) <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />