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Safay and <br /> p Division <br /> 201 W"hingma Ay,0 Box 7082 <br /> County <br /> 14sconsiln Madisml W] 53707-7082 Site Addrras <br /> De artment of Commerce /077 GrY E <br /> Sanitary Permit ApplicationSanitary Pe myNumber w <br /> In accord with Comm 83.21,Wis.Adm.Code,Personal infomsatiou you provide <br /> me be used for"con ws Priva Law 5.0 I m check if Reunion 1 2 3 L <br /> 1. Application Information-Please Print All Infortaatloa State Plan I.D.Number <br /> r oy7ay8 .Sf#e 7760 <br /> 'Property Owoer'a Name <br /> Persil Number 01d-41/7ft.'07-SOD 4jsnYla <br /> gent t t?U, Xd /20ra 07 6x8.2-vo- -av• �s66Soa oro <br /> Property Owna's Mailing Address Property[.Dation <br /> �a 9g t/ / r i¢✓c. <br /> ��• Lot •S T N R JAWCiry,Spk Zip Code Phone Number Lot Number 3 Block Number <br /> 1Subdivision Name CSM Numbcr 404((J q 5 f <br /> z103-532.7 i�3 <br /> U.Type of Building(Check all that apply.) ✓3 <br /> de I or 2 Family Dwelling-Number of Bedmoom 3 0 City <br /> 0 PubbC/Commadal-Describe Uw OVOuge <br /> 0 Sure Owned owashi <br /> Nearest Rod <br /> CTH E <br /> III.Type of Permit: (Check oily one base os,Ilse A.,:Numbering for 1pternal tueJ (Complete line B,If appEIej <br /> A. I p New <br /> Replacement 8 stem Ta k On] amort of tip Addition m :. <br /> S .nem � y Tank ODI Exiatin S an For County tue <br /> B. <br /> ❑Check if Sanitary Permit Previouslyllsaued Permit Number_ Dale Issued <br /> IV.Type of POW I System: (Check all that apply, Numbering Is for laternal up-), <br /> 440 Non-PrewuriradljlCraaod •2I Mound 47❑ an <br /> Sd Filter SOp Constructed Wetland <br /> 220 Preseurized Lo-Ground 410 Holding Tank 48 0 Single Paw 51 O Drip Line <br /> 450 At-Grade 460Acrobic Treatment Unit 490 Recirculating 30❑Other <br /> V.Dis ersallfreatm Ent Area Information: <br /> Design Flow(gpd) DupaW Ata Dupersal Area Soil Application DP Percolation Rik System Elevation FinalGrade <br /> Requited Proposed Rate(GaIsJDaydSq.Fn) (hliollnch) Elevation <br /> )ASO 4,5.0 4.570 <br /> • 7 97.03 48.97 r <br /> VI.Tattle Info CG&Uou lo, , Total Numbu Ma,uhcnx r Prefab Site Steel Fiber <br /> Gallow Gallons of Tanks Plastic <br /> New F.". Corcrek Comhumd Glau <br /> Tmks Ta s • . <br /> 70. DO 000 / <br /> Donner Chamber <br /> 00 <br /> VII.Responsibility Statement-L the undersigned,assume responsibWty for installation of the POW7S shown on the attached pinna <br /> Plumber's Name(Print) umbels Si MP/MPRS Numbs Busineea Phone Number <br /> MK SEPT <br /> IC & EXCA <br /> PlumM225T leaad r- <br /> qpnn R WI 54801 <br /> V111.Coua I <br /> JApptovd ❑ Owner Giver Initial Adverse proud Sulkily Permit Pee(includes,Groundwater.: Date Issued Issuu t Si o Scamps) <br /> p0 <br /> Determination Surcharge Fee) 1754 <br /> I.Y.Conditions of Approval/Reasous for Disapproval <br /> iuo+ eempkk platy(k Wer Ceunry Daly)far rhe ryekm on PePer sol leu tkan Un 114 Leah..u ala <br /> FEB 1 2012 <br /> BURNETr COU <br /> CRI�6.I9R(R. 05/01) ZONi1 NN <br />