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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 /> *6consfn Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce Submit completed form to county if not <br /> [Privacy Law,s. 15.04(1)(m)] ( P tY� y� <br /> state owned.) <br /> ttach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> Coun State SamalryaPen it Number 0,Check i�vision to revio application State Plan 1.D.Number <br /> I.Application Information-Please Print all Information Location: <br /> Property OwnerName <br /> ,Q % Property Location - <br /> " ' 1/4 1/4,S2ST y0,N,R/,((or <br /> Property Owner's 'ling Address Lot Number Block Number <br /> .Bo X73 <br /> City,State Zip Code Phone Number 9ntdwision-Name or CSM Number <br /> II.Type of Building: (check one) ❑city <br /> &— 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑Public/Commercial(describe use):_ P Town of <br /> ❑State-Owned sc p <br /> Nearest Road i <br /> 4)c A,-J <br /> Parcel Tax;Number(s) <br /> - 6 62 <br /> III.Type of Permit: (Check only one box on line A. Check box on lS <br /> ine B if applicable) <br /> A) 1. ew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> 1:1B) Permit Number Date Issued <br /> A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> gNon-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(Gals./day/sq.ft.) (Min./inch) Elevation <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 /> ❑ ❑ ❑ ❑ ❑ <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 /> Plumber's Address(Street,City,State,Zip Code) <br /> OX �`/ 5i/^C-_ , <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Iss ' g gent S' ature(No stamps) <br /> EE <br /> ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />