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-Nanitary Permit Application Safety&Buildings Divisi, <br /> In accord with Comm 83.21, Wis.Adm. Code 201 W.Washington Av&, <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> Department at Commerce <br /> Vis'consin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302[Privacy Law,s. 15.04(1)(m)] (Submit completed p ed form to county if not <br /> state owned. <br /> Attach complete plans to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Permit Num Chc#if revisio to previous application State Plan 1.D.Number <br /> �— <br /> L Application Information-Please Print all tRArnfation Location: <br /> Property at Name _ Property Location <br /> 0.f f �d h nSo n 1/4 1/4,S 1.2TN,R5E <br /> Property wrrer's Mailint Address Lot Number Block Number <br /> 'Ba 55 Cao <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> �I�pt� 1' _ *19ity <br /> 5 g 5 s ) 't�0 5 W-) a, e r //RII Type of wilding: (check one) <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 0Z' ❑Village <br /> ❑ Public/Commercial(describe use): If-Town of <br /> ❑ State-owned G k r) <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) [Nearest Road <br /> 4it,� <br /> A) 1. AsIew System 2. ❑ Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numbe s) <br /> System Tank Only Existin S stem M Q <br /> B) <br /> 13 Permit Numbcr ate Issued <br /> A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> on-pressurized In-ground E] Mound ❑Sand Filter 13Constructed 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.DispersalArea 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Galsdday/sq.R) (Minlinch) Elevation <br /> Z:)(D 2x0 274 7 ), 7 /oma <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 /> S�0 lw�l5� la ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII Responsibility Statement <br /> the undersi ed,assume res onsibi ' for' sta ti f e OWTS shown on the attached plans. <br /> ?lumber's Name(print) lumbo S' ps): MP/MPRS No. Business Phone Number <br /> John Solofra #223779 715-376-2278 <br /> Plumber's Address(Street,City,State,Zip C eI <br /> PO Box 161; Gordon, 54838 <br /> VIII County/Department Use Only <br /> ❑Disapproved I Sanitary Permit F (Includes Gro water Date Iss Issuing Agent Si rc(No <br /> proved ❑Owner Given Initial Adverse Surcharge Fee) ( <br /> [Determination e Q I <br /> M Conditions of Approval/Reasons for Disapproval: <br /> a UC 214 2001 <br /> er <br /> 1 �Ul RNETT COUNTY <br /> Z <br />