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Sanitary Permit Application Safety&Buildings Di11 <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washingto <br /> See reverse side for instructions for completing this application PO Box 0 <br /> NviSeonSin <br /> Department of commerce Personal information.you provide may be used for secondary purposes Madison,WI 53707 0 <br /> [Privacy Law,s. 15.04(t)(m)) (Submit completed form to coup <br /> state <br /> Attach complete plans to the county co s only)for the system,on paper not lethan 8-1/2 x 11 inches in size. <br /> County State Sanitary Permit Numb if evi-4, to previous a p�lic ion State Plan 1.D.Number <br /> 1/6 <br /> I.ApOication Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> 1/4 1/4,S;Z[[�"T4eAAfb,N (, W <br /> Property Owner's Mailing Address Lot Number ,W� <br /> 1,519 1541J. :z- .L 4 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> l� .5400 tS )�S9-Z93S V. 2 13 <br /> II.Type of Building: (check one) ❑City <br /> W 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): XTown of �^ <br /> ❑ State-Owned W►l <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road ,u— <br /> A) I. ❑New System 2. fkReplacement 3. ❑Replacement of 4. ❑Addition to Parceel ax umbers) <br /> System Tank Onl Existing System V <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground ❑ Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground Molding Tank ❑Single Pass ❑Drip Line <br /> ❑At-gTade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Applic7ft.) <br /> Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./dain./inch) Elevation <br /> 300 <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> 2Doo Z �Y-- ►✓ ❑ Cl ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.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 /> �NA,2DA✓ <br /> umber's Address(Street,City State,Zip Co e) <br /> 2.7760 3s W15a W1- S4-sg3 <br /> VIII. County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fe Includes Groundwater Dat Issued Issuing Agent i tuMel <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination �/� <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> bjak /�h�i'fl�t <br /> SBD-6398 R07/00 <br />