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Sanitary Permit Application Safety&Buildings Division <br /> ' In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> iSconsin Madison,WI 53707-7302 <br /> Department of Commerce Personal information you provide may be used for secondary purposes (Submit completed form to county if not <br /> [Privacy Law,s.15.04(1)(m)] <br /> state owned. <br /> Attach complete plans to the county copy only)for the s ste on paper not less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Permit Numb Check if i to previous appli ion State Plan I.D.Number <br /> ems' <br /> 4PA.) <br /> L Application Information-Please Print all Info ti Location: <br /> Owner Name ( Property Location <br /> /t..l 7/S G 1/ I!4z.S/ N,J5E or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State IZip Code Phone Number Subdivision Name or CSM Number <br /> r Ter` w ti S-YS` 3 -2 <br /> II.Type of Building: (check one) ❑City <br /> E31 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> wit of <br /> ❑ Public/Commercial(describe use): <br /> ❑ State-Owned F <br /> III.Type of Permit: (Check only one box online A. Check box online B if applicable) Nearest Road le-eti.L L�K� <br /> A) 1. 40ONew System 1 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel T Nunber(s) <br /> System Tank OnlyExistingS stem t'� '33 O .2 U <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> Won-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 Arca 1 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> _5�_tp Required Proposed Rate(Galsdday/sq.ft.) (Min./inch) I I Elevation <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete stmeted <br /> Tanks Tanks <br /> _ e- bC �v �(� JUO�WeScp ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> 1,the undersigned,assume resp"ibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumbers Signature(no s): MP/MPRS No. Business Phone Number <br /> Plumbers Address(Street,City,State,Zip Code) <br /> d 5 i .SYS'72 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permi (Includes round Date Issued IRo ssuing A t S' <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Detcrminstion <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />