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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 /> `Aseonsin See reverse side for instructions for completing this application 15 Box 7302 <br /> Personal information you provide may be used for secondary purposes Madison, to county 7302 <br /> Department of Commerce (Submit completed form to county if not <br /> [Privacy Law,s. 15.1)4(t)(m)J <br /> state owned. <br /> Attach complete plans to the county copy onW for the system,on paompot less than 8-1/2 x 11 inches in size. (� <br /> County State Samitary Permit Number k' ' 'onto i application State Plan 1.D.Number 4 <br /> 23 6f r 5 <br /> I.Application Information-Please Prilidalf Information Location: <br /> Property Owner Name / lP�ro Location 2 .q� (f, <br /> ei a <br /> Property Owners Mailing Address Lot Number BI Number <br /> 1,,Z7oo dwele-o-s..,j �7_ 6D� c�T <br /> City,State Zip Code Phone Number SubdrAwall Naftne or CSM Number <br /> Ed,e.) V 3 <br /> II.Type of Building: (check one) ❑city <br /> RL 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): @f`r'own of <br /> ❑ State-Owned �$O� <br /> M.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road / <br /> " 6.a s /-)t, O'r <br /> A) 1. ❑New System 2. ?'6placement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Only ExistinR System :Y-2 3.7 o S 2 U <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previouslyissued <br /> IV.Type of POWT System:(Check all that apply) <br /> -Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass O Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other. <br /> V.Dis ersal/Treatmeat Area Information: <br /> L.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application S.Percolation Rate 6.System Elevation 7.Final Gude <br /> Required Proposed Rate(Gels./day/sq.ft) (Min./inch) Elevation <br /> 5_Z_> 6 v 3 9y. � 2,9 x,r 7(/,? <br /> VI.Tank Capacity inTotal #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> s r C /0DD 1166C) 91- ❑ ❑ ❑ 1 <br /> ❑ <br /> 14M 11o� 6� ❑ ❑ ❑ ❑ <br /> 2V .Resp nsibility Statement <br /> I,the undersigned,assume res ibili 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 /> GJ.� a �o`m l t/x� 2 7G al —T OF- G <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Iss ' ens stamps) <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee) 16D [ Q <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07100 <br />