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Sanitary Permit Application Safety&Buildings Division <br /> 201 W.Washington Ave. <br /> In accord with Comm 83.21,Wis.Adm. Code PO Box 7302 nn � <br /> Visconsin <br /> See reverse side for instructions for completing this application Madison,WI 53707-7302 W Personal information you provide may be used for secondary purposes (Submit completed form to county if not <br /> Department of Commerce [Privacy Law,5. 15.04(1)(m)] <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the syste ,on paper not les than 8-1/2x 11 inches in size. <br /> Coun State Sanitary Permit umber ❑ eck if ision,tp `us appli tion State Plan .N in er <br /> �N/`�u%c .� 7 <br /> I.Application Information-Please Print all Information Location: <br /> Properly Owner Name f Property Location `/ <br /> Owner <br /> /7 1/4 1/4,S1 .2 �6 ,N,WIoE(or <br /> Properly Owners ailing Address Lot Number Block Number <br /> O u IV 71r l <br /> tty,state Zip Code Phone Number Subd+vmorrName or CSM Number <br /> II.Type of Building: (check one) ❑City <br /> ❑Village <br /> ,,Z 1 or 2 Family Dwelling-No.of Bedrooms: 5kTown of <br /> ❑Public/Commercial(describe use):_ <br /> ❑State-Owned a <br /> Nearest Road <br /> Parcel Taa p be s o U O <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Perini[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 ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground 13 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 /> g Required Proposed Rate(Gals./day/sq.ft.) (Mi /inch) Elevation <br /> / ,le 0 f-7 o 1 t �- 13 �5=96 5 <br /> VII.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 /> ❑ ❑ ❑ ❑ �— <br /> iG 000 C5- <br /> VIII.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 /> .7Y9 -2 2- <br /> Plumbers <br /> Plumbers Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fe (Includes Groundwater Da su Issuing Ag t Si ps) <br /> roved ❑Owner Given Initial Adverse Sur charge Fee)�A©o, 00 �17d e;L <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />