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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 /> PO Box 7302 <br /> See reverse side for instructions for completing this application <br /> ViMadison,sconsin Personal information you provide may be used for secondary purposes 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)fo the system,on par not less than 8-1/2 x 11 inches in size. <br /> County . State Sanitary Permit Number eck itlevision to previo application State I.D.Number <br /> y rN 43 cam? <br /> I.Application Information-Please Print all Information V Location: <br /> Property Owner Name Property Location HC <br /> RAL- /V CA) <br /> ;:d—c?/C/ /U S V,--j -' 1/4/I��/4,S VO N,R E(or)C <br /> Property Owner's Mailing Address Lot Number Block Number <br /> ® ,s6 — <br /> City,State �( Zip Code Phone Number Subdivision Name or CSM Number <br /> �—JIY I W s-yevo U. 11Z , l <br /> I�It.Type of Buildi . (check one) 0 city <br /> 7� 1 or 2 Family Dwelling-No.of Bedrooms:�� ❑Village <br /> ❑Public/Commercial(describe use):_ lTown of <br /> t <br /> ❑State-Owned W".) i rl er <br /> Nearest Road <br /> Parcel Tax Nu er(s) <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) <br /> 11 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 found ❑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 /> ysra ySv /V / -' 77, 7 �?1-5 <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 strutted <br /> Tanks Tanks <br /> C /400C laov <br /> vrl (00 <br /> I.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans, <br /> Plumber's Name(prin,tl Plumber's Signature(no ps): MP/MPRS No. Business Phone Number <br /> PI is Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit F1�je(Includes Groundwater71� <br /> ate Issued Iss i gnature(No stamps) <br /> rApproved ❑Owner Given Initial Adverse Surcharge Fee / '/Determination "� l �J�7 f <br /> onditions of Approval/Reasons for Disapproval: <br /> NFn- <br /> ZOAt ouN <br /> SBD-6398(R.07/00) <br />