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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 PO Box 7302 Viaconsin Madison,WI 53707-7302 Personal information you provide may be used for secondary purposes <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 rwt less than 8-1/2 x 11 inches in size. <br /> County,i State Sanitary Pe it Numbel n ❑Che revis'on to previous plication State Plan I.D.Number <br /> �.1 Y3 / <br /> I.Application Information-Please Print all Information Location: <br /> Prop rty Owner Name Property Location v <br /> A i c � SEv4A)614,Sa 3 ,N,R��(or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> wQ4e GJ .5 Yd' -3 ( ) <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑Public/Commercial(describe use):_ )Renown of <br /> ❑State-Owned 117e <br /> Nearest Road y- a3 S/( <br /> / .S <br /> Parcel Tax Number(s) 2--33 - ..� <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. 9KReplacement 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 /> 964on-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(GalsJday/sq.R.) (Min./inch) Elevation <br /> , So Gy3 ellS'f `— y7- 9 7./ 9q_99/ <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 I Tanks <br /> ❑ ❑ ❑ ❑ <br /> e,091-C Olid — O00 <br /> q� <br /> �d� 6dL� ❑ ❑ ❑ ❑ <br /> VIn.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's/Name(print) J Plumber's Signatu/re no ps): MP/MPRS No. Business Phone Number / <br /> rl�C �4 ,77- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> !� S'/ ..$�/ /"Gam✓ .� 8-�� <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee ncludes Groundwater Date Issued Issuing nt Si to ps) <br /> *Approved 1 ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination r <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />