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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 /> Vsconsin 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 Submit completed county[Privacy Law,s. 15.04(1)(m)] c p eted form to coon if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> Cty State Sani Permit Number ❑ heckkrev ion to prev us application State Plan I.D.Number <br /> o2rti 3b35 i <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name �c',c Property Location C <br /> -e, ` ' O �zO C' L 1/454 I/4,S,;?Y T3?,N,R/�(or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> S;'/� ,e r L K 0 p <br /> City,State Zip Code Phone Number Subdivision Name or Com"*� y <br /> C J w t sy�7� ( > 838a Kcvoo a/ /�,q-r K <br /> II.Type of Building: (check one) ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ own of <br /> r-- <br /> ❑State-Owned <br /> ee—N o hJ <br /> Nearest Road <br /> Par <br /> cellax Numbers _ <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. KNew 2. ElReplacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) 11 Permit Number Date Issued <br /> A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> oNon-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 Proposed Rate(Galslday/sq.ft.) (Min./inch) Elevation <br /> .3av deo ado , s 9,/7 y5;1� <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> / Tanks Tanks <br /> Se r.c Doo — lead /,�orw esc o ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) // lu^ <br /> Plumbees Sig//nature M <br /> stamps): P/MPRS No. Business Phone Number / <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ,&(r>,- Spy -5//--�. oft ' d sY8 �2 <br /> IX.County/Department Use Only <br /> �� ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin [Signa o stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee)c <br /> Determination --!-t' OM.OD <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R 07/00) <br />