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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> �sconsinSee reverse side for instructions for completing this application PO Box 7302 <br /> Department of Commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> Attach—complete Tans to the county co only)for the state owned.) <br /> P ( tY PY Y) system,on pape of less than 8-I/2 x 11 inches in size. <br /> County C Slate Sanitary Permit Number eck if vision to previou application Stale Plan I.D.Number <br /> SU <br /> 4-59a g g 59zo/7 <br /> I.Application Information-Please Print all InformationLocation: <br /> Prope Owner Name <br /> ( ) Property Location <br /> � <br /> 1011011, <br /> �� /��� snr� <br /> Property Owner's Mailing Address 1/4 FI/4,S./ T N,R f(or <br /> f {� ` J Lot Number Block Number <br /> City,State jdc / Phone Number <br /> Subdivision Name or CSM Number <br /> /nom✓ �/T �C) ( ) <br /> II.Type of ilding: (check one) ❑City <br /> "W—1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ AIqvwn of <br /> ❑ State-Owned © 14�t-/�-�tj0/ <br /> Nearest Road <br /> e-6"j <br /> Parcel Tax Numbers) <br /> III.Type ofPermit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. w 2. LJReplacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only <br /> B) <br /> Existing System Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground i2adound ❑ Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass 13 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.DispersalArea 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch <br /> 3� — ) Elevation <br /> 3° , � f 4' Oct <br /> VII.Tank CapaciTy in Total M of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> ,[ t <br /> Z/m 500 x— ❑ ❑ ❑ ❑ <br /> VIII.Respo sibility 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(n tamps): MP/MPRS No. <br /> / nosiness Phone Number / <br /> Plumber s Address(Street,City,State,Zip <br /> oxJ / --5'1 -e- <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Dale Issued Iss7#4 <br /> Signa stamps) <br /> Approved ]FlnlOwner Given Initial Adverse Surcharge Fee) ..,�[[ <br /> Determination alt' 3co 8-23- o� <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> 1 —T— <br /> SBD-6398(R.07/00) <br />