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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 /> Visconsin See reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for second purposes Madison,WI 53707-7302 <br /> Department of Commerce p Submit completed form to coup S <br /> [Privacy Law,s. 15.04(1)(m)] ( P county not i <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. U <br /> County State Sanitary Permit Number ❑ ck i�ision to previou application State Plan I.D.Number R, <br /> tr/`/V L 4 006/54 TT <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> 1/4 1/4,S 7 TY6,N,R/ or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSA�r <br /> f/ /�!� S5�/� ( ) /C/s. r irje✓ /"/ids 3 <br /> II.Type of Building: (check one) ❑City <br /> - or 2 Family Dwelling-No.of Bedrooms: — ❑Village <br /> ❑Public/Commercial(describe use):_ 0 of <br /> ❑ State-Owned 0/r <br /> Nearest Road c <br /> //O t1J /'r ✓�. <br /> Parcel Tax Number(s)oao- _ - <br /> I11.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) L w 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 /> OIon-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 T Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <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 structed <br /> Tanks Tanks / 4 <br /> s e ficMJ OoJ / j/��4�/ ❑ ❑ 11 ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.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 <br /> pq stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only 7 <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin ge rgnatu o stamps) <br /> {Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination ,2 rJ <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />