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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 /> See reverse side for instructions for completing this application PO Box 7302 <br /> Nvis C' OnSln 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 Su <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper of less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Permit Number ❑C e'k if revision to revious plication State Plan I.D.Number <br /> 58 g81 3(el <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location >� <br /> r' 461/1/45k✓1/4,S f2TJ R��(or� <br /> Property Owner's Mailing AdElress Lot Number Block Number <br /> City,State Zip Code <br /> �J Phone Number Subdivision Name or CSM Number <br /> II.Type of Building: (check one) ❑city <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> At Public/Commercial(describe use):_ PJ Town of / <br /> ❑State-Owned G Q <br /> Nearest Road <br /> p4 s` <br /> Parcel Tax Numbers Q/ - 224? -z <br /> I11.Type of Permit: (Check only one box on line A. Check box on line B if applicable) J <br /> A) 1. New 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> t@Non-pressurized In-ground ❑Mound ❑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 1 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 /> yy� .3a GSA '7 !03. 0 tl< l8 <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 structed <br /> Tanks Tanks <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plum is Name(print) Plumber' ignature Mss): MP/MPRS No. Business Phone Number <br /> I3,�6 .�"� �j/3 6S�-2Scn <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin t Sign re stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />