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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 /> Visconsin See 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 /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x i l inches in size. state owned.) <br /> County Q Stam Permit Number ❑C k if revision to previous plication State Plan I.D.Number <br /> f�Nr v c. d L <br /> I.Application Information-Please Print all Information Location: <br /> Property Owne�r/Name ]� Property Location G <br /> �1/4 s�/4,S�eT � ,N,Ri7E(or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 3o GD C �.7`/✓ AV — <br /> ---. <br /> City,State Zip Code Phone Number SWWwiigietf-I.1ame or CSM Number <br /> II.Type of Building: (check one) - ❑City <br /> D( 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ 159rown of <br /> ❑ State-Owned A),? A) <br /> Nearest Road <br /> Parcel Tax Number(s)O _ �I <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) l <br /> A) 1. New 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) <br /> ❑A Sanitary Permit was previously issued I <br /> Permit Number Date Issued <br /> IV.Type of POWT System:(Check all that apply) <br /> .bCNon-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 3.Dispersal Area 4.Soil Application 5.Percolation 7Rate _6_.,_S­ys1emlevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.It.) (Min./inch) Elevation <br /> 30o 7 -� �g 9 � <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 <br /> Tanks <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> [Plumbe:es Namj(pri Plumber's Signature o stain MP/MPRS No. Business Phone Number <br /> d y%�6/�► �.�- ��-7G9/ 3Yy-�� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> KE'*Approved <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Is in C eQ❑Owner Given Initial Adverse Surcharge Fee) b6 �jDetermination (/ 1��-1onditions of Approval/Reasons for Disapproval: <br /> SEP NET3 <br /> URT COUNTY <br /> ZONING <br /> SBD-6398(R.07/00) <br />