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Safety&Buildings Divisio <br /> Sanitary Permit Application 201 W.Washington Avt <br /> t In accord with Comm 83.21.Wis. Adm. Code PG Box 730 <br /> See reverse side for instructions for completing this application Madison,WI 53707-73C <br /> `V,SC'Onsiln Personal information you provide may be used for secondary purposes (Submit completed form to county if m. <br /> Department or commerce [Privacy Law,s. 15.04(I)(m)i state owned <br /> Attach com tete plans(to the county copy only)for the system.on paper not less than 8-1/2 x I I inches in size. ' <br /> County State S it P rmil Numb ❑Check if re inion o revious application State Plan 1. D.Number ` <br /> Location: <br /> 1. <br /> I. A lication Information - Please Print al In <br /> io to Property Location ^ <br /> Property Owlier Name r sela�/1 aAatr, �+ <br /> ��/ mbd �'1�1 1/4 1111S TN or 1 <br /> Lot Namber' v Block Ntunber <br /> Property Owners Meiling Address %� •L,a_ � <br /> StS6 �dJ�G� `j,pc% o 3a-qll s- a l- Sw bar <br /> Zip Code Phone Number Subdivision Name or M Number <br /> City.State y1�7 Z <br /> ❑City / f if <br /> �I Type of Building: (check one) ❑village <br /> ( I or 2 Family Dwelling—No.of Bedrooms: I;kTown of <br /> Cl Public/Commercial(describe use): oe <br /> ❑ State-owned Nearest Road / /^/ <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) L G <br /> ,, 1. X'New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax NumbeKs) <br /> S stem Tank Only Existing System p Issued <br /> Permit Number ( Q— O r <br /> B) <br /> ❑A SanitaryPermit was reviousl issued <br /> IV.Type of POWT System: (Check all that apply) ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> pQ Non-pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑Pressurized In-ground Recirculating ❑Other: <br /> ❑At-grade ❑Aerobic Treatment Unit p g <br /> as /p�� `l N 1A <br /> V Dis ersal/Treatment Area Information: 4.soil A lication 5.per, Rate Y.System ElevationLal Grade <br /> I.Design Flow(gpd) 2.Dispers a 3.Dispersal Area PP /d9Required �5 Proposed Rate(Gals./day/sq. ) (Min./inch) f/, <br /> 0 6 377 `- 7, <br /> Capacity in Total N of facti, Prefab Site Steel Fiber- Plastic <br /> VI Tank Gallons Gallons Tanks Con- Con- glass <br /> Information creta strutted <br /> New Existing <br /> Tanks Tanks ❑ ❑ ❑ ❑ <br /> El 13 <br /> Li <br /> VII Responsibility Statement <br /> I the tmdetsi ned assume res onsibilit for installation of the POWTS shown PP e�Noched lens. Business Phone Number <br /> Plumber's Name(print) / Plum Si rc(nos ps): - 41/77 /�< 2`4/9 ql <br /> lumbers dress(Street,City,State,Zip C <br /> 11b 'L4 o <br /> VIII County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent Signature No st p <br /> 4-Approved O Owner Given Initial Adverse Surcharge Fee)-12 tZ <br /> Determination / <br /> =Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />