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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 /> See reverse side for instructions for completing this application PO Box 7302 <br /> ` isconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Sub nit completed forth 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 4ches in size. <br /> County State Spnntraryf rt it Number ❑Check if revision to previous application State PI 1 I.I,�OSz <br /> u�,�e L� Vcj <br /> umber <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner N er Property Location <br /> / ` / Govy �rl <br /> OG tai / / L`J C 1/4 1/4,S/ Ty0,N )( E(o,(D <br /> Property Owner's Mailing Address Lot Nund,er Block Number <br /> City,state Zip Code Phone Number Subdivision Name or CSM Number <br /> cwltr�Mo/ur/ W;r SyO J '7 ( ) V. 19 <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑V illag <br /> Public/Commercial(describe use):_ moo`n f <br /> ❑ State-Owned 0,4 <br /> Nearest adSair 1 a8 r1 _ .D I <br /> Parcel T Numbers �� O O, <br /> IIl.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) I. ew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) 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 ❑Mound ❑ Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground Pit3olding 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.Sy tem Elevation 7.Final Grade <br /> Required Proposed Rate(Galslday/sq.ft.) (Min./inch) Elevation <br /> 30v <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 struaed <br /> Tanks Tanks <br /> o Doty 3ood S�p r,J ❑ El ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <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 o stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ,Qox Si V -S-;/- e ms w 5Y87 -Z" <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Is uin nt Sign o stamps) <br /> fd'Approved ❑Owner Given Initial Adverse 1 Surcharge Fee) ��71y r(17 <br /> Determination IP U <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> No kGA 5> -we-E dma A Awls <br /> SBD-6398(R 07/00) <br />