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t Sanitary Permit Application Safe ty&Buildings Dim <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W. Bo Washington <br /> See reverse side for instructions for completing this application <br /> iseons�n Personal information you provide may be used for secondary purposes Madison,WI 5 53707 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to countylii" <br /> state o <br /> Attach com lete plans to the county copy only)for the system,ona e of less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Perni N ber eck i r Vis to pmvio application State Plan I.D.Number <br /> I.AppTication Information-Please Fr1rit all Information IjLocation: <br /> Property O.fw eer Name Property Location ��, <br /> 1/4 1/4,SL//��1d4bN, o <br /> Property Owner's Mhifinlf Address Lot Number Block Number- <br /> 2 - 1+ <br /> City,State Zip Code Phone Number Subdivision Name or CSM Numbe <br /> � . X43 15 )%6- 0075(0 V - I92 3508 <br /> II.Type of Building: (check one) ❑City <br /> '% 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑ Public/Commercial(describe use): �9vown of <br /> ❑ State-Owned 0.4KL*ND <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road L5 <br /> A) 1. X New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Only Existing System 4 27 057 830 <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ANon-pressurized In-ground ❑Mound ❑ Sand Filter ❑Constructed Wetland <br /> ❑ Pressurized In-ground ❑ Holding Tank ❑Single Pass ❑ Drip Line <br /> ❑At-grade Cl Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(GalsJday/sq.tt.) (Min./inch) Elevation <br /> 648 ,'1 3- 9 7a <br /> VI.Tank Capacity in Total ii of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> 10vo 1000 1 5k*4W ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> ?lumbers Name(print) Plumbers Signature(no stamps): MP/MPPRSSS No. �+ Business Phone Number �7 <br /> 4/ri1J•cf� � i�+�"' �J� J' ��/ <br /> Plumber's Address(Street,City State,Zip Code) <br /> 2.77(0 3S W£8sr WI. 54893 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Grou water Date Aill <br /> ed Issuing A en "i e <br /> *2kpproved ❑Owner Given Initial Adverse Surcharge Fee !!Determination U <br /> IX. Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />