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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 /> `fisconsin 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)] X� <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on pap of less than 8-1/2 x 11 inches in size. <br /> County State SSaani Permit Number Check yf revision to re'ou application State Plan I.D.Number <br /> 00 <br /> I.Application Information-Please Print all Information of b Location: <br /> Property Owner Name Property Location JIM I , <br /> Or 6 e/ e Sc 1/4SE 1/4,S -J>T z/o,N,WA(or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> Meo Ale <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> II.Type of Building: (check one) ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ R'Town of <br /> ❑ State-Owned 0/7,6 <br /> J /y Nearga aoqd u <br /> / Parcel Tax[[Number(s) <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) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> M 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.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 /> 300 1�429 1 Y3(o . 7 9� z 975 <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 stmcted <br /> Tanks Tanks <br /> ❑ ❑ ❑ ❑ ❑ <br /> ar�G' <br /> VIII.Responsibility Statement <br /> 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plum 's Name(print) Plumby' [gnat (no ps): MP/MPRS No. T7��4' <br /> ess Phone Number <br /> d / V� /�fdfs t�j1 2soa <br /> Plumber's Address(Street,City,State,Zip Code) _ <br /> -�� 2 /S 74 S-/ <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issui ent S' stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> *4) <br /> 9tiF 9 <br /> SBD-6398(R 07/00) <br />