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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21, Wis.Adm. Code 201 W.Washington Ave. <br /> Wisconsin See 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 plans to the count co only)for the s stem,on paper not less than 8-1/2 x 1 I inches in size. state owned <br /> ".&)Q AJC.. State Sanitary Permit N hec f vision jo previous app'cation State Plan 1.D.Number <br /> I.Application Information-Please Print all Infor ation o Location: <br /> Property Owner Name T Property Location <br /> to 1 V (~� l C..J R�•"A 6�r J`-El/4 .5 1/4 Sad T�{ W <br /> Property Owner's Mailing Address Lot Number <br /> 1fb <br /> Block umber <br /> � h�E7�! �111�2 ��, <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> �)6-) jams rte► 5537 qs �oCl-(67Zf0 C&M U/6 )D//3 <br /> II Type of Building: (check one). ❑City <br /> 1 or 2 Family Dwelling—No.of Bedrooms: r ❑Village <br /> ❑ Public/Commercial(describe use): 0,Town of Nt VX? <br /> State-owned <br /> tJ III Type of Permit: (Check only one box on line A. Check box on-line B if applicable) Nearest Road <br /> A) 1. Jew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System l <br /> Permit <br /> B) Permit Existin S em © -• <br /> Number Date Issued <br /> E3 SanitaryPermit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> $Von-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 Dis rsal/freatment-Area Information: <br /> 1.Design Flow(gpd) 2.DispersalArea 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gels/day/sq.ft.) (Min.l.1 t Elevation, <br /> C �- �. <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 Meted <br /> Tanks Tanks Af — t_Lg <br /> tmp lore) ( �bU r✓7c�, ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII Responsibility Statement <br /> I the undersistried,assume rest)onsibility for installation of the POWTS shown on the attached plans. <br /> Pltunbees Name(print) I Plumb atu (nos MP/MPRS No. Business Phone Number <br /> ffoN�f/I!� E- Dtr:js 4 7[�J 715-D 2e*7L 3 09 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> -2 /3 5 STATS RD ul s483� <br /> V>II County/Department Use Only <br /> 11 Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) 9; <br /> Determination `y'6�00. 0-D <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> Ur�l't ^ y�V <br /> MQY ) NO 1 2q0! <br /> ( ` '-' - 4N1G IJN?Y <br /> SBD-6398(R.07/00) <br />