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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 BURNETT <br /> Visconsin <br /> Madison.WI 6-315—7162 Sanitary Petra mbar(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 <br /> Sanitary Permit Application State Plan I.D N tuber <br /> In accord with Comm 83.2 1,Wis.Adm.Code,personal information you provide 1404182 <br /> may be used for secondary purposes Privacy Law,sl5.04(1 xm) 1rYA Address i f different than mailing address) <br /> I. Application Information-Please Print All Information Ltlb5 GThi O <br /> Property Owner's Name Parcel# Lot is 1 awizsi <br /> MIKE MARTIN 034-1519-0 100 csH V 2z <br /> 200 <br /> Property Owner's Mailing Address Property Locatio <br /> 1548 GRANT ST. .I <br /> N 5 '/., N '/., Section 19 <br /> City,State Zip Code Phone Number <br /> BELOIT WI 53511 608-751-0318 37 $circle one) <br /> 11.Type of Building(check all that apply) T N; R r t, <br /> ❑+ l or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Nam CSM Number <br /> Public/Commercial-Describe Use N/A N/A <br /> ❑State Owned-Describe Use [:)Cfty_aillagi Qrownship of Trade Lake <br /> RI.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 0 New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modific ion to Existing System <br /> B. 0 Permit Renewal ❑Permit Revision 0 Change of 0 Permit Transfer to New List Previous Pen in Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.TvDe ofPOWTS System: Check all that apply) <br /> 0 Non-Pressurized In-Ground 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil ❑At-Grade ❑ E ingle Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground 0 Holding Tank 0 Peat Filter ❑Aerobic Treatment Unit ❑Recirc dating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line 0 Gravel-less Pipe 0 Other(explain) <br /> V.Dis ersaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) 1 System Elevation <br /> 450 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Sie Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Const wed Glass <br /> New Eziseng <br /> Tanks Tanks <br /> Septic or Holding Tank 2600 2600 1 HUFFCUTT X <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the a ched plans. <br /> Plumber's Name(Print) Plumber's Signal MP/MPRS Number Ru iffiess Phone Number <br /> ROBERT HARDINA 824825 715-986-2508 <br /> Plumber's Address(Street,City,State,Zip e) <br /> 477 170 AVE TURTLE LAKE WI 54889 <br /> VIII.Coun /De rtment Use Ontv <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Is uin g Signatu o Stamps) <br /> Surcharge Fee) {J MM ``�r'' t <br /> ❑Owner Given Reason for Denial �+ W s)p� b7 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Amish complete plata(to use County only)for the system on paper not Ira aun 81/3 x I I inches in its <br /> SBD-6398 (R. 01/03) <br />