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Sanitary Permit Application safety uildings Di 77 <br /> In accord with Comm 83.21. Wis.Adm. Code 201 W. Washington P <br /> Immizcon5in you Y P Y See reverse side for instructions for completing this application PO Box 7 <br /> Personal information provide may be used for secondary purposes Madison. WI 5371?--7 <br /> Department of Commerce <br /> [Privacy Law,s. 15.04(I)(m)] (Submit completed form to count. if <br /> to own <br /> Attach complete plans(to the county copy only)for the system,on --T <br /> _paer not less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Permit Nu ber ❑Check if revis on to previous application State Plan I.D Number <br /> I.Application Information-Please Print all Information Location: <br /> Property OwnerName /' Property Location `c <br /> C OA)N i C� AL4E11454,e)1/4.S p N. or <br /> Property Owner's Mailing Address Lot Number Block Numb( <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 2Y -7 2 <br /> li II Type of Building: (check one) ❑City <br /> 1 ort Family Dwelling-No.of Bedrooms: _ _ ❑village <br /> Public/Commercial(describe use): *l own of <br /> O State-owned 1 41 <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. ❑New System 2. 1,i4[Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> S stem Tank Onl Existin S stem p . <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was reviousl issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground KMound ❑Sand Filter ❑ Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑ Single Pass ❑ Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑neirculating ❑ Other: <br /> V Dis ersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.DispersalArea 3.Dispersal rea 4.Soil Application 5.Percolation Rate 6 System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 3� 0 360 -3 a� 99� / <br /> VI Tank Capacity in Total 4 of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> ° ° <br /> V I Responsibility Statement <br /> I,the undersigned,assume responsibility for installadi m 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 /> d 2G <br /> P umber's Address(Street,City,State,Zip Code) <br /> %cv --S-/el ;,O—'e-.J yS'73 <br /> VIII County/Department Use Only <br /> ❑Disapproved Sanit try Permit Fee(Includes Groundwater Date Issued Issui Agent Signature(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surd arge e) p <br /> Determination ` ,,;Loa l -S Q'Zj <br /> IX. Conditions of Approval/Reasons for Disapp oval: <br /> SBD-6398(R. 07/00) <br />