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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 /> 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 th system,on paper n4Qt less than 8-1/2 x 11 inches in size. <br /> CountyV State Sanitary Pe it Number ❑Ch if rey)sion to previous plication State Plan I.D.Number <br /> I.Application Information-Please Print all Information Z Location: <br /> Property Owner Name Property Location <br /> AG v IV 1 _r, r � ) t I <br /> CSM 11CtvL �(.I"t` ' /4 /4,S 2,I T�N,R` (o W <br /> Property er's Mailing Address Lot Number Block Number <br /> C)-�3o Wt►l 10 kA, (Oro t'v-- 3 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Num <br /> 'baa/ 6f m 1 13 o C ✓ `� , ( a V` <br /> II.Type of Building: (check one) ❑city <br /> ❑Village <br /> � 1 or 2 Family Dwelling-No.of Bedrooms: Town of <br /> ❑Public/Commercial(describe use):_ i❑State-Owned ��Neprree;tRoad /t / !/� eel <br /> Parcel Tax Number(s _t ,O 2b0 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) <br /> ❑A Sanitary Permit was previously issued Permit Number Date Issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground ACK4ound ❑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 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> tiE) 3rD adv i 173. r(c:::, 9c/ ?C=� <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existings--t `I_ _0, trete strutted <br /> Tanks Tanks 6 <br /> ❑ ❑ ❑ ❑ <br /> c XOCAWo <br /> t <br /> r7tt <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibili4y for installation of the POWTS shown on the attached plans. <br /> Plumber's Nam (print) Flu tier's Signa ( tamps): MP/MPRS No. Business Phone Number <br /> QIS (ger V_ 2zSZz 71 S 6— <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date I sued Issuing Age Si turg o ps) <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee)�asv. p0 ,e lC�` <br /> Determination O( V ` �� <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />