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Safe y and Buildings Division County L <br /> \voeij. 201 W. W shington Ave., P.O.Box 7162 2r1e- 0a-0 5(} (j <br /> rsevnsin Ma ison, WI 53707-7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide l°s C9 q(7 <br /> may be used for secondary purposes Privacy Law,s15.04(1)(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 /> tn ' <br /> iVlilcG Actin ( , <br /> Property Owner's Mailing Address _____'----Property Location <br /> � <br /> Po. e (rs7 51N % se �b:S 34 T 1 N.R I Z E <br /> City.State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Nanic CSM Number <br /> Matsiocti I, wl -S355 t3- to 55- 3fIS (.main's(?uh — <br /> II.Type of Building(check all that ap• y) ❑City <br /> i or 2 Family Dwelling-Number oft droom `+' <br /> OVillage <br /> ❑Public/Commercial-Describe Usc a'K <br /> -- 19Towrshi p y <br /> ❑State Owned �,_ Nearest Road <br /> 1J—Sat i-J-Satn Cir. <br /> III.Type of Permit: (Check only one box on line A(number' scheme for,internaa1 use). Complete line B if applicable) <br /> A. � ,❑ <br /> 1'New 2 ❑ Replacement System 3 ❑ Replacemcn�of 6 Addition to Fur County use <br /> System Tank Only Existing System _ �. <br /> B <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Nu then 4' Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering schcs cis for internal use) <br /> .14 Ea Non-Pressurized In-Ground 210 Mound 47.0 Sand Filter % 50 Constructed Wetland <br /> 22 0 Pressurized In-Ground 41 ❑ Holding Tank 1 48❑ Single Pass '' ✓ 51 Drip Linc <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating ❑Other <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Perc.platron Rate =�Systert„n-.aniGon Final Grade <br /> Required ,(Oc> Proposed Rate(Gals./Days/Sq.Ft.) (Mir../Inch) -1 l-ia Elevation <br /> (000 '"cl y4 •t 'mob I <br /> i i • 9,lf0 <br /> VI.Tank Info Capacity in . Total Number Manufacturer Prcfa, rte Steel Fiber Plastic <br /> Gallons Gallons of Tanks 1 Concrete Constructed Glass <br /> Ncw Existing <br /> Tanks Tanks <br /> Septic or Holding Tank tu,so IL, C) I M«e., X <br /> Dosing Chamber — 80 1 a <br /> X <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature 4.412/MPRS Number Business Phone Number <br /> bodivc tN Ive-ok z- Avid_ U.,. ' 00a0i(DS 831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> • Lot 301 Cry. }-};,,,y. K wauoakee,, W1 53 <br /> VIII. County/Department Use Only <br /> • <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agent Signal c(No ' m <br /> Surcharge Fee) d✓ �- <br /> ❑ Owner Given Initial Adverse �7 — ��� <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 Inches In size <br /> Can T /•r n r■ it e.r .i... <br />