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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 /> See reverse side for instructions for completing this application <br /> isconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> 5Box 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 not less than 8-1/2 x 11 inches in size. <br /> ;Dunt State Sanitary Permit Number ❑CheSk iif�si n to previous application State Plan I.D.Number <br /> 41/`A1 c 3 �f = Y <br /> I.Application Information-Please Print all Informatio Location: <br /> Property Owner Name / Property Location <br /> -e/ r P�� <br /> jhee/SO�tJ 1/4 1/4 S Ty11 ,N,R/4E or W <br /> Property Owner's Mailing Address W /� Lot Number Block Number <br /> i ,r^O e) k S /T' 5-.Tl-. <br /> City,State y Zip Code Phone Number Subdivision Name OrCSM <br /> >Number <br /> o$a✓,/Ie /19� ss��� !v 5`l X33—/9�'7GNSDA/S LAS�Iof � <br /> II.Type of Building: (check one) 02 ❑city-;9- 1 or 2 Family Dwelling-No.of Bedrooms. Towan of <br /> ❑ Public/Commercial(describe use): k1k1+4 <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. ❑New System 2. (9-Replacement3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Ont Existina S stem a 12 <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System: (Check all that apply) /� <br /> 'ill Non-pressurized In-ground ❑Mound d 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 Rate76. Final Grade <br /> Required Proposed Rate(Gals./day/ .ft.) (Min./inch) Elevation <br /> l 97,JK <br /> VI.Tank Capacity in Total #of anufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> S'e4'r, Dvc) /Odo r JU0CWe5Cio ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume res onsibili for installation of the POWTS shown on the attached plans. <br /> Plumbers NName(pri t) s <br /> Plumber's Signaturo stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> o�Siy S��e-v �%✓..� SY�72. <br /> VIII.County/Department Use Only <br /> Disapproved Sanitary Permit Fe (Includes Groundwater Date Issued Issuin A ent Si ps <br /> �ApprovedOOwner Given Initial Adverse Surcharge Fee)termination I / J <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />