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Sanitary Permit Application Safety&Buildi D'visiot <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Wash Ave <br /> Visconsin See reverse side for instructions for completing this application x 730: <br /> Department of Commerce Personal information you provide may be used for secondary purposes Madison,WI -730: <br /> [Privacy Law,s. I5.04(1)(m)) (Submit completed form to c f no <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. sta ed.' <br /> County State it Permit Number ❑Check if re isi n to revious application State Plan L D.Number M <br /> I.AppTication Information-Please Print all Information d Location: <br /> Property Owner Name <br /> Property Location /�� <br /> Property Owner's Mailing Address 1/4 1/4,S ,N R or W <br /> 1000 Vik4dSlArm <br /> Lot Number Block Numbe <br /> City,State Zip Code $hone Number JimSubdivis n Name or CSM Number <br /> w S2 $?n-460463,11 <br /> II.Type of Buildin (check one e� <br /> 1 or 2 Family Dwelling-No.of Bedrooms: _ s2 _ 0'4�` ❑Village <br /> ge <br /> ❑ Public/Commercial(describe use): grown of A <br /> ❑ State-Owned S <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) N crest Road <br /> UNC u <br /> A) I. �sNew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to arce Tax Number(s) <br /> S stem Tank Onl Existing System <br /> B) Permit Number Date Issued Q - <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> Non-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 Propo dd� Rate(Gals./day/sq.ft.) (Min./inch) EI vation <br /> (/f/Il g Lig . I e - _ 9s. z- <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 /> ❑ ❑ ❑ ❑ <br /> cl <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached fans. <br /> Plumber's Name(print) Plumber's Signature(no stamps): MP/MPRS No. r Business Phone Number r <br /> umbers Address(Street,City State,Zip Co e) <br /> 2-77 0 3S W�gsr WI- 54893 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued ISSW A entS**a , ps) <br /> i'lApproved ❑Owner Given Initial Adverse Surcharge F U16 Determination t j <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />