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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> Visconsin See reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned.) (� <br /> Attach complete plans(to the county copy only)for the system,on paper no ess than 8-1/2 x 1 I inches in size. <br /> CountyA y�� State$anit��r i�Number ❑C k'f revisi n top iou�a ication State Plan 1.D.Number <br /> I.Application Information-Please Print all Information �( Location: <br /> Property Owner Name Property Location <br /> �s L- v6 ' <br /> 1/4 1/4,S N,IY IC(or <br /> Property ee ling Address Lot Number Block Number <br /> Li ae <br /> City,State // Zip Code Phone Number Subdivision Name orC—SIA Yymber <br /> b �r SyBy ( > -41 <br /> lI.Type of Building: (cbeck one) ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ Tow,nonoff�j <br /> ❑ State-Owned z�I c ..S O A-.) <br /> Nearest Road <br /> Past <br /> Parcel TAx Number(s) 'S <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. PtNew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV Type of POWT System: (Check all that apply) <br /> Ao-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 /> Requt ed Propo d Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> S o o �6 1 o / 5- ?4, 7 7k, <br /> VII.Tank Capacity llons in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information GaGallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks I Tanks <br /> 57_e,ellc 750 7-50 <br /> 1SOd Sock ❑ ❑ ❑ ❑ <br /> I.Respo sibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber s Name(pri Plumb s Signature(no ps): MP/MPRS No. Business Phone Number <br /> �JAy�6/�, �aL 7-z <br /> Plumber's Address(Street,City,State,Zip Code <br /> -, y �,/"� <br /> IX.County/Department Use Only <br /> / ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issu' g ent Sign (No stamps) <br /> Approved ❑Owner Given Initial Adverse I Surcharge Fee) ��0 t <br /> Determination (J� <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />