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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 /> See reverse side for instructions for completing this application PO Box 7302 <br /> Visconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper of less than 8-1/2 x 11 inches in size. <br /> Countyn State SanAe�3 Number C ck if isiog to previou pplication State Plan�5 B 7Z <br /> u/ *0 e 7J �b 77 11-2 <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location q <br /> � m o -0G- 5 1/4 1/4,S"24T3/N,R E(o) <br /> Property Owner's Mailing Address Lot Number Block Number <br /> v /6 'S 3 <br /> City,State Zip Code Phone Number SxbdiuicieaName or CSM Number <br /> IL Type of Building: (check one) ❑City <br /> �--1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ Mown of J <br /> ❑State-Owned $0 e,.4;—:, <br /> Nearest Ro <br /> ,ti L� <br /> Parcel TCt N ber s) --2(5 6 8- 0 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. placement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> $) Permit Number Dale Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground Omound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.DispersaVTreatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate i6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.R.) (Min./inch) Elevation <br /> bl <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 I Tanks <br /> 'et lDU /6Dd 13 ❑ ❑ 11 <br /> y <br /> 00 add ❑ ❑ ❑ ❑ <br /> Respo sibility 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 stamps: MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) / <br /> IX.County/Department Use Only 1-2 <br /> W/Approved <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issui ent Signature stamps) <br /> BI Approved ❑Owner Given Initial Adverse Surcharge Fee) LL 20 O�P f� O �� <br /> Determination `� J <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />