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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 1 <br /> ` isconsin Personal information you provide may be used for secondary purposes Madison,W153707-7302 <br /> Department oi'Cammerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> County State Se�Permit Number ❑C�k if re inion to preyio application State Plan I.D.Number/ <br /> I.Application Information-Please Print all tInformation Location: <br /> Prop Owner Name (.1�� Property Location <br /> 1, t Uc.y!`e 1 1/4 1/4,S T Z16N,R (or)W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> Sc-''Q- f <br /> Ci ,State Zip Code Phone Number Subdivision Name or CSM Number - C <br /> �G-tre�—n <br /> 11.Type of Building: (check one) O City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑Public/Commercial(describe use):_ #-T-own of <br /> ❑State-Owned '6l=O—H— <br /> Nearest 11r- ad .n�r-� `�LY <br /> Parcel Tax Number(s)od&—'�bwolnryb <br /> III.Type ofPermit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-groundF{clding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> 4�© Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing _ crete structed <br /> Tanks TanksCTe <br /> 3 ❑ ❑ 11 <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> 9PIbet's Name(print) PI bet's Signature no [amps): MP/MPRS No. Business Phone Number <br /> ( � <br /> P o?a - <br /> um A dress S City,State,Zip Code DOCK LAKE <br /> SEPTIC & DIRT WORK <br /> IX.County/Department Use Only VV9502 UUCK LAKE ROAD <br /> 01r-❑Disapproved SanitaryPermit Fm(Includes Groun issuin ge Signatu ps) <br /> Approved ❑Owner Given Initial Adverse I Surcharge Fee) / <br /> Determination `M 0000 <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R 07/00) <br />