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(��2�GJrn,D <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Was PO BO Box Ave. <br /> NViseonsin See reverse side for instructions for completing this application ox 7302 <br /> Madison,WI 53707-7302 <br /> Department or Commerce <br /> Personal information you provide may be used for secondary purposes (Submit completed form to county <br /> if not <br /> [Privacy Law,s. 15.04(1)(m)j state owned.) <br /> Attach complete plans to the county copy only)for system,on paQer not less than 8-1/2 x I 1 inches in size. ( l <br /> County State Sanitary P 't umber ❑ k ifoa us application State Plan 1.D.Number v 1 <br /> L A cation Information-Please PrWt Al WoKmation Location: <br /> Property Owner Name Property Location <br /> DOLO 1/4 1/4 S N E or W <br /> Property Owners Mailing Address Lot Number <br /> 4qio M d iUv- <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> i N 3 Z `Y33- -S.- <br /> 11.Type of Building: (Check one) 3 ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): Alrown of <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road 5 <br /> A) 1. ❑New System 1 2. Replacement 3. ❑Replacement of 4. ❑Addition to Parcel T Numb ) <br /> stem I Tank Only Existing S stem is sm <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 ❑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.Diapersal Area 3.Dispersal Area 4.Soil Application S.Percolation Rate 6.System Elevation 7.Final Grade <br /> _, Re uirod� Pro ed Rete(Galslday/sq.ft.) (Min./inch) Elevation <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New I Existing trete strutted <br /> Tanks Tanks <br /> Iwo <br /> ❑ ❑ ❑ ❑ <br /> L &W� ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I the undersianed.assume M!p2nsibility for installation of the POWTS shown on the attached plans. <br /> Plu bees Name(print) Plumbers Signature(no s): MP/MPRS No. Business Phone Number <br /> S - IS- S(s- 415'1 <br /> P bees Address(Street,City,S Zip C ) I, <br /> AC;4� <br /> VIII.County/Department Use Ohly <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin t Si Ps <br /> pproved ❑Owner Given Initial Adverse Surcharge F C r <br /> Determination I <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />