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Safety and Buildings Ulvislon county <br /> Wyk 201 W. Washington Ave.,P.O. Box 7162 Burn t47r1� <br /> iseonsin Madison, WI 53707-7162 Site Address <br /> Department of Commerce W/0 yu'Y 7e <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for second purposes Privacy1)( <br /> Law, .04 m ❑ Check if Revision <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> Property Owner's Name Parcel Number <br /> T Gdurek clef jjo4 03`7eo <br /> Property Owner's Mailing Address Property location 6Ovt.(OfS /¢ 1 O <br /> 4/'49/22 �w 729 4f 'A:S `` T Tgr N,R /S -E <br /> City,State Zip Code Phone Number Lot Number + Bleck Number <br /> Subdivision Name CSM Numbe <br /> $Ire 1.4/, S`4�7ed lis-.-WV ot35s" osm V. f /� <br /> II.Type of Building(check all that apply) ❑City _ <br /> C1 or 2 Family Dwelling-Number of Bedrooms d. ❑Village <br /> ❑Public/Commercial-Describe Use ®Township <br /> ❑State Owned Nearest Road <br /> 76 <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal tile). Complete line B if applicable) <br /> A. I.Q New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to Far County use <br /> system I I Tank Only Existing S stem <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44,K Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Welland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> Sod , <br /> _575 — 9i 94-0 <br /> s�C� ss9.8 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Si eel Fiber Pl;,itic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks 1 <br /> Septic or Holding Tank Q - /000 <br /> Dosing Chamber <br /> VII. Responsibility Statement- t,the undersigned,assume responsibility for installation of the POWTS shown on the attached pLins. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phon:Number <br /> /?rck- f>'a /Cr'"J /C>-W.� l 9�s�s—/ 7is �G6- 4is 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 760 /i�rt� 3-s" �t/t Est e.- <br /> VIII Count /De artment Use Only <br /> Approved ❑ DisapprovedSanitary Permit Fee(includes Groundwater Date Issued Issum ge ignatur o Stall ps) <br /> Surcharge Fee) <br /> C3 Owner Given Initial Adverse `J �jo� r0 0r <br /> Determinadon 1 -r <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> OCT <br /> IRNETT COUNTY <br /> Attach complete plans(to the County only)for the system on paper not less than Sr/2.tl inches io sue ZONING <br /> SBD-6398 (R. 05/01) <br />