Laserfiche WebLink
r <br /> Sanitary Permit Application Safety&Buildings Division <br /> ' In accord with Comm 83.21,Wis.Adm. Code 201 W.WashingtonAve. <br /> i ` See reverse side for instructions for completing this application PO Box 7302 <br /> siConsin Personal information you provide may be used for secondary purposes Madison WI 53707-7302 <br /> Department of Commerce (Submit completed form to coup ' <br /> [Privacy Law,s. 15.04(1)(m)) P h'if not <br /> state owned. <br /> �/Attach complete plans to the count co only)f e system,on paper of less than 8-1/2 x 1 I inches in size. <br /> City UQN l State Sanitary Pe iCt Number ck if rpyisiioon to revi plication State Plan 1.D.Number <br /> L,_ <br /> P <br /> I.Application Information-Please Print all Inforimatidn Location: <br /> Property Owner Name Property Location <br /> 5/npl )&(a(;L S IQI'I/4 1/4 S P�'Tql,N,R14Eo< W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 76r-31 MIZ s/. _t) <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> II Type of Building: (check one). -2 ❑City <br /> '' 1 or 2 Family Dwelling-No.of Bedrooms:____e 4L B�7 D 6�tf u Lo�2 ❑Village <br /> O Public/Commercial(describe use): Town of S/.UZSS <br /> 0 State-owned <br /> III Type of Permit: (Check only one box on line A. Check box on line.B if applicable) __ Nearest Road f� <br /> A) L ❑New System 1 2. XlReplacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Only Existing System O 3A- 5- Q/— 3 e <br /> B) <br /> 13 Permit Number Date Issued <br /> A Sanitary Permit was previously issued <br /> N.Type of POWT System:(Check all that apply) <br /> PILNon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Welland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V DispersaVrreatment Area Information: <br /> 1.Design Flow(gpd) 2.DispersalArea 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.R) (Min.finch) Elevation <br /> VI Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> �1 Tanks Tanks LDAC <br /> Lom�Jin�ndn� i00 /OGa7�Do / l�/JrI�UzP"5 ❑ ❑ ❑ ❑ <br /> ho <br /> O ❑ ❑ ❑ ❑ <br /> VII Responsibility Statement <br /> the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumbees Name(print) Plumber' ' aturc(nos MP/MPRS No. Business Phone Number <br /> P4uf�i7PL !ol0'1O ?! l <br /> Plumber's Address(Street,City,State,Zip Code) <br /> /67/3 S• ST,0 n <br /> VIII County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing ent Signature(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination a b D <br /> IIf.bonditions of Approval/Reasons for Disapproval: <br />