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Safety&Buildings Division <br /> Sanitary Permit Application 201 W.Washington Ave. <br /> In accord with Comm 83.21,Wis.Adm. Code PO Box 7302 <br /> ViSCOn' <br /> See reverse side for instructions for completing this application Madison,WI 53707-7302 <br /> sin Personal information you provide may be used for secondary purposes (Submit completed form to county if not <br /> Department of Commerce [Privacy Law,s. 15.04(I)(m)] state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x I I inches in size. <br /> County Stat Permit Number ❑Check ifrevision to previous application State Plan I.D.Number <br /> I.Application1414 <br /> Information-Please Print all Information Location: <br /> Property Owner Named /�l Property Location <br /> /d/c, ( Aho �O1194d/ 4,S T 77N,R I�(or)W <br /> Lot Number Block Number <br /> Property Owne Mailing Address �b <br /> /417 ,via 5 l <br /> City,State Zip Coder P��N her 7 -11$ <br /> 7 Subdivision Name or CSM Number <br /> AvOC /'f fkitr 7/� ( ) ❑City <br /> II.Type of Building: (check one) ❑village <br /> 1 or 2 Family Dwelling-No.of Bedrooms: '0 Town of <br /> Public/Commercial(describe use):_ <br /> ❑State-Owned a !� <br /> Nearest.Ropd/Jr�a <br /> Parcel Tax N r b )j p — 7 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) 6. ❑Addition to <br /> A) 1. ❑New 2. Replacement 3. ❑Replacement of 4. 5. <br /> System System Tank Only Existing System <br /> B) Permit Number Dau Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Mound ❑Sand Filter [I Constructed Wetland <br /> ❑Non-pressurized In-ground <br /> ❑Pressurized In-ground WHolding 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 /> VII.Tank Capacity in Total #of Manufacturer Prefab Site jSteelFiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con-New ExistingCrete structed <br /> Tanks Tanks� ppa ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Business Phone Number <br /> Plumber's Name(print) Plumb 's S' nature(nos p): MP/MPRS No. <br /> 4/ 73 7/S y�6� <br /> lumber's Address Street,City,Slate,Zip Code) <br /> IX.County/Department Use Only <br /> Sanitary Permit Fee(Includes Groundwater Date Issued Is in Agent Si <br /> 11 Disapproved (No stamps) <br /> x I Approved ❑Owner Given Initial Adverse Surch a Fee <br /> Determination r <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />