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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 /> Ase See reverse side for instructions for com letin this a ltcation PO Box 7302 <br /> onsin personal information you provide may be used fogseconda Madison,WI 53707-7302 <br /> Department of Commerce Y P Y secondary purposes Submit completed form to county[Privacy Law,s. 15.04(1)(m)] ( P 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 /> County t�h State Sanitary Permit Number ❑Check if rev' ion to revi s application State Plan L D.Number <br /> Y/ AI.Aimlication Information-Please Print all Information Location: <br /> Property Owner Name / Property Location <br /> A 7'-- J OA1 Joh SW 1/4.IW1/4 S�� U ,N, (Eor <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 3.0 Co /aa al C . 6 ti,� <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> waoel6ur / Ss 6 7 O -5"fs CS is30 If 30-3/ <br /> Il.Type of ilding: (check one) ❑City <br /> l- 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): ii;-Town of <br /> ❑ State-Owned Qa/C/,fhd <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearer V 3S— <br /> A) 1, UdNew System 1 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Only Existing System G.,)0 9 ,� <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> g on-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(Gals./day/sq.ft.) (Min./inch) Elevation <br /> x3oU aro / o100 , <br /> VI.Tank Cap%Tanksd <br /> Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information GGallons Tanks Con- Con- glass <br /> New trete strutted <br /> Tanks <br /> Z ,9 Iso / V1ej-)Ij67Ife r <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached lans. <br /> P��lumm�bees Name(print) Plumber's Signature(no stamps): MP PRS No. Business Phone Number <br /> WQ l/a c,e T 13epjo,t I'VaAAA_ <br /> Plumber's Address(Street,City,State,Zip/Code) / ` /— <br /> ���� i�e end ��Y- YY�P1��/- VJ. <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fe (Includes Groundwater Date Issued Issuing Age Signa a(N ps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination Q0 L��� <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />