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Safety&Buildings Division <br /> 201 W-Washington Ave. <br /> Sanitary Permit Application PO Box 7302 <br /> In accord with Comm 83.21,Wis.Adm. Code application Madison,WI 53707-7302 (�` <br /> See reverse side for instructions forbe used fogs thisoondary purposes <br /> (Submit completed form to county if not x <br /> you provide may state owned.) <br /> ;onsin Personal informationrivacy Law,S. 15.04(1)(m)] <br /> .,hent of Commerce <br /> co only)for the system,on paper not less than 8-11,4 x 11 inches in size. <br /> Attach complete plans(to the county PY eck if revision to p "ous application State PI '3 umber <br /> Slate Sanitary Pe ember e CD(0 <br /> County .O Location: <br /> G nS 8. property Location G <br /> I.Application Information-Please Print all Information 1/4N 1/a S ao T3�•N'R/�E(or) <br /> Property Owner ama Block Lot Number Number <br /> property Owner's Mailing Address <br /> Subdivision Name or CSM Number <br /> 7b .121P.121PPhone Number <br /> 6 <br /> Zip CodeZ <br /> / <br /> city,state 5S6 i3 ( a r/ )2 S'J _`�"'� ❑city <br /> G/ S A G Ali 1]Village <br /> ,/ g: check one) own of <br /> II.Type o Building:D ( No of Bedrooms: 3 <br /> or 2 Family Dwelling- A��f rQ�5 <br /> ❑Public/Commercial(describe use):_ {"— �$Y-7.) <br /> Nearest Road` <br /> ❑State-Owned <br /> Parcel Tax N ber(so C/ yG D <br /> 5 14Existing System <br /> 6. ❑Addition to <br /> Check box <br /> III.Type of Permit: (Check only one box on line O•Rep acement oDate Issued <br /> f e B if applicable <br /> A) I. ew 2. ❑Replacement 3' Tank Only <br /> System System Permit Number <br /> B) ❑A Sanitary Permit was previously issued <br /> Sand Filter ❑Constructed Wetland <br /> IV.Type of POWT System:(Check all that apply) ❑"ound Cl Single Pass ❑Drip Line <br /> ❑Non-pressurized In-ground ❑Holding Tank ❑Other: <br /> In-ground ❑Recirculating <br /> ❑Pressurized In-g ❑Aerobic Treatment Unit <br /> ❑At-grade <br /> on 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Elevation <br /> V.DispersaVTreatment Area InArea 3.Di ersal Area 4.Soil APP <br /> 2.Dispersal Area P Rate(GalsJday/sq.ft.) (Min./inch) X12 n <br /> 1.Design Flow(gpd) Required Proposed _f 77, <br /> d <br /> y SG Steel Fiber- Plastic <br /> / Prefab Site <br /> 5-0 V5-,- Manufacturer glass <br /> Capacity in Total #of Con- Con- <br /> V1I•Tank Gallons Gallons Tanks trete strutted <br /> Information New, Existing ❑ ❑ ❑ <br /> Tanks Tanks ❑ <br /> ❑ 1_1 ❑ <br /> 1/06) •---- 610 D <br /> uM <br /> V I1.Responsibility Statement Business Phone Number <br /> MP/MPRS No. <br /> I,the undersigned,assume responsibility installationnt (no stampsOWTS shown on the attache plans. d <br /> Plumber's Name(0 t) ! �` __;2 7 �� <br /> .PA-Cle- All <br /> Z <br /> Plumber s Address(Street City,State, ip Code) <br /> I6 s,y s: ature o stamPs) <br /> Issuin Agent Sign (N <br /> County/DepartmentDse Only sanitary ((to 1 <br /> permit Fee(Includes Groundwater Date Iisssued <br /> ❑Disapproved surcharge Fee) <br /> Approved ❑Owner Given Initial Adverse a5bCOO <br /> Determination roval. <br /> X.Conditions of Approval/Reasons for Disapp <br /> SBD-6398(R.07/00) <br />