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Safety&Buildings Division <br /> Sanitary Permit Application 201 W.Washington Ave. <br /> p0 Box 7302 <br /> In accord with Comm 83.21,Wis.Adm. Code application Madison,WI 53707-7302 <br /> Visconsin <br /> See reverse side for instructions for completing this ndP oses Submit completed form to county if not <br /> be used for secondary pure state ownedpersonal information ou provide y Law,s 15.04(1)(m)) <br /> Department or commerce <br /> State Plan I.D.Number <br /> Attach corn Tete lens to the coon co onl forthe <br /> f stern,onc a v'not less than 8-1/2 x 11 inches in size. <br /> Olks <br /> State Sanitary Permit NQ <br /> er <br /> County Location: <br /> I.A ication Information-Please Print all Information Property LocationA T41 N E <br /> Property Owner Name u 1/4 S ` Block Number <br /> C,I y�'r{' Lot Number <br /> Prop Owric{s ailing Address 1. <br /> S r 1 A W <br /> Phone Number Subdivision Name or CSM Number <br /> T! Zip Code /� �A� L a <br /> City,State <br /> n <br /> ❑City <br /> � <br /> [3 Village <br /> II.Type of Building: (check one) Townof ,�5 <br /> X 1 or 2 Family Dwelling-No.of Bedrooms: !� �/ <br /> ❑ Public/Cottunercial(describe use): Nearest Road <br /> ❑ State-Owned c <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) WP 1 axN�e s) <br /> ❑Replacement of 4. ❑Addition to /�i0j�_ � <br /> A) 1, New System 2. ❑Replacement 3. Tank Onl Existing S stem v Date Issued <br /> System k10.nlNumber <br /> B) <br /> ❑A Sam Permit was reviousl issue ❑Sand Filter ❑Constructed Wetland <br /> IV Type of POVVT System: (Check all that apply) ❑Mound ❑Drip Line <br /> In-ground ❑Single Pass ❑Other: <br /> on-pressurized Iund ❑[-lording Tank ❑Recirculating❑Pressurized In-ground ❑Aerobic Treatment Unit <br /> ❑At- ade 6.System Elevation 7.Final Grade <br /> 4.Soil Application 5.Percolation Rate Elevation <br /> V.Dis ¢rsal/Tr¢atm¢nt AreSsinformation,Dispersal Area Rate(Gals./day/sq,ft.) (,in./inch) <br /> 1.Design Flow(gpd) p,2. quirer proposed <br /> Required ,1 '-1 <br /> 3DB �9 �3Z Prefab Site Steel Fiber- Plastic <br /> Total #of Manufacturer Con glass <br /> Capacity in Con- <br /> VI.Tank Gallons Gallons Tanks crete structed <br /> Information New Existing ❑ <br /> Tanks Tanks ❑ ❑ ❑ <br /> 000 -- I o0o I oet�l�St n ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement Mp the No. Business Phone Number <br /> I,the undersi ed,assume res onsibplumbe{s installation <br /> Signature(no stampsO S shown on je���s�s' r _ <br /> Plumberr'sttName(print) <br /> [•IIb Co e) W'. S48q 3 <br /> umber's Address(Street,City State,Zip�� ��� <br /> -1160 <br /> VIII.County/Department Use Only ludes Groundwater Date Iss d <br /> Issuing A Si o tamps <br /> Sanitary Permit Fee(In.: <br /> ❑Disapproved Surcharge Fee) � <br /> Approved ❑Owner Given Initial Adverse V <br /> Determination for Disapproval: <br /> rover: <br /> IX.Conditions of Approval/Reasons <br /> SBD-6398 R07/00 <br />