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Sanitary Permit Application Safety&Buildings Divisior <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 730' <br /> Frsonainformation you provide may be used for second purposes Madison,WI 53707-730'Slj <br /> Department of Commerce y �p � Submit completed form to tour no--C, <br /> Law,s. 15.04(1)(m)] ( P county if no <br /> state owned.o <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x I I inches in size. ap <br /> County may^ State SanP i Number 0 Check ifrevisiontoprevious.application State Plan 1.D.Number <br /> I.Application Information-Please Print all Information ) � <br /> Property Owner Name Property Location <br /> L91-L2 W / <br /> Property Owner's Mailing Address Lumber Bl1/4,S,36 T Bl or <br /> J Lot Number umber <br /> /'c 01 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> fflype of ilding: (check one) ❑city <br /> tr I or 2 Family Dwelling—No.of Bedrooms: ❑Village <br /> U Public/Commercial(describe usey NTown of <br /> ❑ State-owned SC a <br /> III:Typeof Permit.(Check only otte box on firm A. Check box ort lino R ifappticable) Roa�,� <br /> �� all hark c� <br /> A) I. ❑New System 2. tld Replacement 3. ❑Replacement of 4- ElAddition to Parcel Tax Number(s) <br /> System Tank Onl Existing System Od _ /36 — <br /> B) Permit Number Date Issued <br /> QA Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> melon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ElAigrade E rAerobic Treatment Unit El Recirculating ❑Other: <br /> V DispersaVrmatment Area Information: <br /> 1.Design Flow(gpd) 2.DispersalArea 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> �4ufTed P R ( q ftT fMh*/ *Y i Elevation <br /> 5�S v yoo, A. Saw. ao , s- yyoo - 97.00` %&sa I-yy.Sp <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 /> ��� / —0 -70— ❑ ❑ <br /> DDO /000 IM1'/CJ GrJ CAic rLJ/Y <br /> Q C7 ❑ ❑ ❑ <br /> VirResponsiIiiTify Statement <br /> I the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plamber'sSignatmr:(no snffnps)- lsfPft0PR5Nb. Bu;iness Phone Number <br /> _,VIla-,e 7. /�eh�k ' P7� 76 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Cffe e ,-I- vee fry Iii_ S�r�� <br /> VIII-County/1Tepartment Use Only <br /> ❑.Disapproved Sanitary Permit Fee LIncludes Groundwater Date IssuedIssuing Agent ignature(No ) <br /> roved ❑Owner Given Initial Adverse Surcharge F �fv <br /> Determination / ' � 721 <br /> IX.Conditions of Approval/Reasons for Disapproval: <br />