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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 BurnettisCOnsin Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> (608)266-3151 <br /> Department of Commerce $ () <br /> Sanitary Permit Application State Plan I.D.Number <br /> bi <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl5.04(l)(m) Project Address(if different than mailing address) <br /> I. Application Information—Please Print All Information 9865 Elbow LK.Rd. <br /> Property Owner's Name Parcell# Lot# Block# <br /> Robert Finch III /! #3--7 / 006-2432-01100 <br /> Property Owner's Mailing Address W GG�I Property Location <br /> NEI/4—NEI/4 <br /> 9865 Elbow Lake Rd. <br /> Gov.Lot NA Section 32 <br /> City,State Zip Code Phone Number <br /> Siren WI <br /> 54872 715fi89-2632 T 38 N; R17 W (circle one) <br /> IL Type of Building(ckeek all that apply) <br /> 111 or 2 Family Dwelling—Number of Bedrooms 3 Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial—Describe Use Csm# Pending <br /> ❑State Owned—Describe Use ❑CiTy_❑Village ITominship of Daniels <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System 46 Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System <br /> R. ❑ Permit Renewal L1 Permit Revision Ll Change of El Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> W.Type of POWTS System: Check all that apply) <br /> N Non—Pressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Weiland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter 0 Leaching Chamber ❑Drip Line ®Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: Infiltrator Standard-W-Quick 4 <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(st) System Elevation <br /> 450 .7 643 sq.ft EISA=20sq.ft x 34=680 Cell#1=89.00'Cell#2=87.00' <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New I Existing <br /> Tanks Tanks <br /> Septic or Holding Tank 1000 1000 1 Wieser Concrete x <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the underls4ned,ajoene r,possibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) PI 's Si Kum MP/MPRS Number Business Phone Number <br /> Robert Carlson # 135655 (715)653-2500 <br /> Plumber's Address(Street,City,State,Zip Code, <br /> 3572 115th Street Frederic WI 54837 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issui t Sign o Stamps) <br /> Surcharge Fee) y 5��/D p <br /> ❑Owner Given Reason for Denial l7�O �� V <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plam(to the County only)for the system on paper not less than 812 a 11 inches in size <br /> SBD-6398 (R. 01/03) <br />