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Sanitary Permit Application Safety&Buildings Division <br /> S In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> 1 isconsin Madison,WI 53707-7302 <br /> Department of Commerce Personal information you provide may be used for secondary purposes <br /> [Privacy Law,s. 15.04(l)(m)] (Submit completed form to county if not <br /> state owned. <br /> Attach co Tete plans to the county copy only)for the system,on paper not less than 8-1/2 x t I inches in size. <br /> County DD State Sanitary. 't r ❑Check' 'si to re ' application State Plan I.D.Number <br /> I.Application Information-Please Print aff Ififfirninflon Location: <br /> Pro Owner Name t Property Location e/` ��55_ c <br /> 06 e� /yj/4 �m /S � 1/4 1/4,S r TX6,N, E <br /> Property Owner's Mailing Address Lot Number Block Nit tuber <br /> Fe v,2- /`e.4j-q✓'e-e- -�a/. 4� 16 <br /> City,State Zip Code Phone Number Subdivision Name or eSM Number <br /> y iJ6 u r f.J,� St/8 3 e X099 e-A-su r �s/.�-� , <br /> II.Type of uilding: (check one) — ❑city <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: 1 ❑Village <br /> ❑ Public/Commercial(describe use): Morown of Nj;�GK 5-e^j <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> ('G fFS4/'GrZs <br /> A) 1. ❑New System 1 2. Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numbers) _ <br /> System Tank I Existing System /oZ57 7� O S <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previousl issued <br /> IV.Type of POWT System:(Check all that apply) — �L ,j 4 40✓ P.+� <br /> n-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 PreposedC� Rate(GalsJday/sq.ft.) (MinJinch) Elevation <br /> 93,-7 <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 /> s•� �ic 7s D i /G ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersignmA assume res tLbility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(pri Plumbees signs nue stamps): MP/MPRS No. Business Phone Number <br /> Plumbers Address(street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit kqo(Includes Gmter Date Iss Issuing t i ) <br /> roved ❑Owner Given Initial Adverse Surcharge Fee) a J <br /> Determination CJ / <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />