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Safety and Buildings Division County <br /> ` 20 W. Washington Ave., P.O. Box 7162 54, <br /> iseonsin Madison, W[ 53707 -7162 Site Address <br /> Department of Commerce 7,.9y �reins�e� 1To/ <br /> Sanitary Permit Application — Sanitary Permit Number --- <br /> In accord with Comm 83.21, Wis. Adm. Code, personal information you provide (1 <br /> may be used for seconds u ses Privacy Law. 15.04(1)(m) ❑ Check if Revision �/C q oo � SCJ <br /> I. Application Information-Please Print All Information Sia e Plan LD. NumberjNjumber <br /> 'lc7 / <br /> Property Owner's Name <br /> Parcel Number <br /> ;ke- 14,1Wee -xu ORO-g3aS- <br /> Property Owner's Mailing Address Property Location <br /> �(,f 35 37,1, Ave. S•ty,State Zip Code Phone Number Lot Nrr BSubdivision Name umer <br /> n),els m N, SS�ti �lJ - �p I SOS7 6A*WOW SGv.�es <br /> n. Type of Building (check all that apply) <br /> ❑City <br /> ❑ 1 or?Family Dwelling-Number of Bedrooms <br /> L V illage <br /> ❑ Pubhc!Comntercial -Describe Use -- <br /> ❑ <br /> .rI'ownship QIO 1c&w h State Owned Nearest Road <br /> F/rmst�e� <br /> III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> A. <br /> 1 ,WNew 2 ❑ Replacement System E0nIv ent of 6 � Addition to For County use <br /> S-stem Fxistin System <br /> B. ❑ Check if Sanitary Permit Previously Issuember Date Issued <br /> IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 XNon-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Constructed Wedand <br /> 22❑ Pressurized In-Gruund 41 ❑ Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-G.-ade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V. Dispersal/Treatment Area Information: <br /> Design I-low(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) 74.4 Elevation y2,0 <br /> uppe✓ <br /> 673 6 . 7 <br /> lower- 1941.( <br /> VI.Tank Info Capacity in ToW Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank IWO - 1 G Gv ✓ <br /> Dosing Chamber <br /> VII. Responsibility Statement- 1,the undetsigoed,assume responsibility ror installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number --JBusiness Phone Number <br /> L06RP /�s '�-` �-� 22S'g S 1 715= 866- 4157 <br /> lumber's Address(Street.City,State, Zip Code) - <br /> 2.7-7 (o o f-}w 35 gg �48 3 . <br /> V I. Count 'Department Use 1 _ <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater i a'w e s <br /> PP PP .� N e [ µIre(No Stamps) <br /> Surcharge Fee) ] /''� 1 <br /> ❑ Owner Given Initial Adverse t'1�s n 0 a `J <br /> Determination i , <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> )URNETT COUNTY <br /> ZONING <br /> Anach complete plans(to the County only)for the system on paper not lees than S 2 x II Inches in size <br /> SBD-6398 (R. 05101) <br />