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00,cc c7x <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> `�seonsin 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 coup co only)for system,on paper not less than 8-1/2 x 11 inches in size. [� <br /> Count State Sanit Pe it ❑C ck if rev'sion'to previou pplication State Plan I.D.Number <br /> Ale <br /> I.Application Information-Please Print all Information oC Location: <br /> Property Owner Name - Property Location <br /> 1/4 1/4,S 140 TION,R�E or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 23-cZ 14S ft AV. NW W -T7 -10zz. 0.7. 1 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> A400JEA M KI 55304 G1 )1.7-1433 QA1<tAdQ <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 2 ❑Village <br /> ❑ Public/Commercial(describe use): `Town of <br /> �//��,,,, <br /> ❑ State-Owned V/I�N1J <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road AEAS 51ry <br /> A) 1. JU New System 2. ❑Replacement 1 3. ❑Replacement of 4. ❑Addition to Parcel Tat No Cr(s) <br /> System Tank Onl ExistingSystem3Z5* 01 sm <br /> B) Permit Numberr�+) Date Issued <br /> A SanitaryPermit was previouslyissued 0?59 0 0— — <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 /> 3°a Required Proposed Rte(Gals./day/sq.ft.) (Min./inch) Elevation <br /> A0 45Z 3.z s.s <br /> VI.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 /> C IX0I NbRwt sco ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print)) Plumber's Signature(no stamps): MP/MPRS No.�+ 'Business Phone Number <br /> FG414ao If0Pf4W5 <br /> lumber's Address(Street,City,State,Zip ode) <br /> 2.7760 .3S' WSW W1- _54893 <br /> VIII.County/Departmifnt Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date I00 s ed Issuing Agent 'gna , <br /> proved ❑Owner Given Initial Adverse Surcharge Fee) / 0 ' <br /> VVVVVV Determination r <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />