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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 /> `vs` 6psinSee reverse side for instructions for completing this application PO Box 7302 <br /> Department of Commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> (Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned. <br /> Attach comp] te plans to the countyco 1 for the system,on a er of less than 8-1/2 x 1 I inches in size. r— <br /> Count State SitaryPermit Nu her ❑Check if revision to previou application State Plan I.D.Number <br /> I.Application Information-Please IrBint all Informati Location: <br /> Property Owner Name Property Location h <br /> KE� CLp'2K 1/ 0/4,S Z9 T ,N,R o w <br /> Property Owner's Mailing Address of Number Blocll Numb <br /> (0250 N'�� sfi <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> G,u.E )Ws Md, 550+4 - 1299 <br /> .Type of Buildi g: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): own of �/A/1 p <br /> ❑ State-Owned V� <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road/r.l-V <br /> A) L 0 lew System 2. ❑Replacement 3. El Replacement of 4. ❑Addition to Parcel T NuCmbbe� s) <br /> System I Tank Only Existing Systemftj:?=Q Q 1 20D <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System: (Check all that apply) <br /> Mon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> 0 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.Percolafion Rate 6.System Elevation 7.Final Grade <br /> Required Proposed( <br /> Rate(Gals./day/sq.R.) (Min./inch) Elevation <br /> d0 d104 , "1 2.$ q .2 <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> lib IZ5b 1 �,,,i ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibilityfor installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no19�=l <br /> MP/MPRS No. Business Phone Number <br /> Plumber's Address(Strreet,,,City,Sta)e,Zip Code) <br /> VIII.County/Department Us my <br /> tfA <br /> ❑Disapprod Sanitary Permit (Includes Groundwater Date Issued Issuing ge Signa QUI ps) <br /> WO <br /> veved ❑Owner Given Initial Adverse Surchar a Fee) CSS/ <br /> Determination J /d' " <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />