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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 /> PO Box 7302 <br /> ` s�ed►nsin See reverse side for instructions for completing this appli n Madison,WI 53707-7302 <br /> Department or Commerce Personal information you provide may be used for second ( u mic pleted form to county if not <br /> [Privacy Law,s. 15.04(1)(m)] state owned. <br /> Attach complete plans to the county copy only)for the system.on paper t less than 8-1/2 x I 1 inches in size. U) <br /> County State Sanitary Penni er ❑C c if rev orrL o��previous plication State Plan 1.D.Number <br /> I.Application Information-Please Print all nfor ation tl Ot Location: <br /> Property Owner Name Property Location <br /> /,L1 s at 1/4 1/4 Sa4 T N E W <br /> Property(Tuner's Mailing Address Lot Number Block Num <br /> ber- <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> W IJi- es 3 2/9- ) 20S- <br /> II <br /> 2osII Type of Bui ing: (check one). ❑City <br /> Cl 1 or 2 Family Dwelling—No.of Bedrooms: ❑village <br /> O PubliclCommercial(describe use): 9Town of [ �� <br /> O State-owned <br /> III Type of Permit: (Check only one box on line A. Check box on-line B if applicable)._ _ Nearest Road ,.�^ <br /> A) 1. )Pkew System 1 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to a cell Tax Numbber(�s)D2Z Dd <br /> System Tank OnlyExistingSystem -q/OS <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> on-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> 13 Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> v Dia ersaVTreatment Area Information: <br /> 1.Design Flow(gpd) 2.DispersalAma 3.Dispersal Arca 4.Soil Application 1 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Galslday/sq.R) (Minlinch) Elevation <br /> 9'7l4 " Ele/60-0 <br /> VI Tank Capacity in Total N of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks I Tanks G41 <br /> 75C51 750 f4D, El <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII Responsibility Statement <br /> I the undersigned,assuMjMaonsibiliry for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plum ' sture no MP/MPRS No. Business Phone Number <br /> o/vz1� 1� i Ott �2D 7/s- 2-W-3SOS <br /> Plumber's Address(Street,City,State,Zip Code) <br /> cc,'7 [ 3 S- C�T,ATe--- <br /> VIII County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date 1 ed IssuingrtMSistonps) <br /> pr <br /> oved ❑Owner Given Initial Adverse Surcharge Fee) 1 21 a� <br /> Determination ' Ir <br /> IX.Conditions of Approval/Reasons for Disapproval: <br />