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i Safety&Buildings D ion <br /> Sanitary Permit Application 201 W.Washing <br /> In accord with Comm 83.2 1.Wis. Adm Code <br /> PO Bo. <br /> I Madison,WI 5370 y <br /> �� See reverse side for instructions for completing this application oses (Submit completed form to county t <br /> of&consnn Personal information Pyou provide may S. be used <br /> for <br /> secondary purl) state o ) <br /> Department of commerce <br /> Attach com lete fans to the court c 6 r on Ofoh •k f etemonn a or revi us a ps cation 8 State Plan inches DNumber <br /> County <br /> State S t e <br /> Location: <br /> I. A ication Information-Please Print all Information Property Location <br /> Property Owner Name tL, 1/4 114,g�T j ,N. E o W <br /> k *ftlr eAJ Lot Number Block Number <br /> Property Ow/n�ees Mailing Addressa <br /> V "e ✓�'" �- Phone Number Subdivisio Name or CSM`umber <br /> City,State Zip Code (r U q NWY4 <br /> J <br /> cceM��l�1DAl MN- 55458 ( ) V <br /> ❑city <br /> II.Type of Building: (check one) ❑VillageTown of <br /> 1 or 2 Family Dwelling-No.of Bedrooms:_4 J(•t/ J <br /> ❑ Public/Commercial(describe use): <br /> ❑ State-Owned Nearest Road <br /> III.Type of Permit: (Check only one box on line A. Check boxReplacon line B if applicable)on to pia cel beds) foV <br /> A) 1. New System 2. ❑Replacement 3. Tank Only <br /> of 4. ❑ isdnmSv tem <br /> system Date issued <br /> Permit Number <br /> B) <br /> ❑A Sanita Permit was reviousl issued <br /> IV.Type of POWT System: (Check all that apply)�r:vtound ❑Sand Filter ❑Constructed Wetland <br /> ,�y, ❑Drip Line <br /> C3 Non-pressurized In-ground ❑ Holding Tank ❑ Single Pass P <br /> E3 Pressurized In-ground ❑Other: <br /> C3 Aerobic Treatment Unit ❑Recirculatin <br /> ❑At- ade <br /> 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> V.Dis ersaUl reatment Area Information: Elevation <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area (Gals./day/sq.pp ) Min./inch) O <br /> Requ red Proposed RateR. ( ��, /DO, (� <br /> (�00 �00 02 1 . 0 0 <br /> Plastic <br /> Total of Manufacturer Prefab Site Steel Fiber- I <br /> VI.Tank Capacity in Con- Con- glass <br /> Information <br /> Gallons Gallons Tanks trete strutted <br /> New Existing <br /> Tanks Tanks ❑ � ❑ ❑ I ❑ <br /> /200 /200 ❑ ❑ ❑ I o <br /> G � � <br /> V I.Responsibility Statement <br /> I,the undersi tied,assume res onsibili for installation of the POWTS shown P v1tthe attached plans. Business Phone Number <br /> Plumber's Name(print) Plumber's Signature(nu stamps): r�r/ I _ /5 7 <br /> Gi�A,�lJ Ui✓ J J i <br /> umbels Address(Street,City State,Zip Co e) e�71 1 'I. <br /> 2.7760 3-> WG W D <br /> VIII.County/Department Use Only lssui Agent Signature(No stamps) <br /> Sanitary Permit F (Includes Groundwater �Date Issued <br /> ❑Disapproved Surcharge Fee) ;a ,00 I" /-�� <br /> Approved ❑Owner Given Initial Adverse ---iKKf <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07100 / <br />