Laserfiche WebLink
Safety and Buildings Division rS1n1Mry <br /> 201 W. Washington .Ave., P.O. Box 7162rnC <br /> Wisconsin Madison, WI 53707 -7162 Site <br /> Department of Commerce 5'7( 11lai lac(•_ h,} <br /> Sanitary Permit Application mit Numbe`''''ppppIn accord with Comm 83.21, Wis. Adm. Code, personal information you provide Revision /ys�07� <br /> may be used for secunda purposes Privacy Law, sl5.04(1)(in) / <br /> 1. Application Information -Please Print All Information Sure Plan I.D. Number <br /> Coe�a 3a <br /> Property Owner's Name Parcel Number <br /> Dan I(endr/4(e6on 0 12- ¢20"7 - 0 S$OCA <br /> Property Owner's Mailing Address / Property Location av-6 col-3 <br /> Sg3s I�I'(/i f(^ SY✓rem A' 'A . r;5 7 T 4V N, R t,5- <br /> City. <br /> SCity.State Zip Code Phone Number Lot Nu,7�nher Block Number <br /> Subdivision Name CSM Number <br /> y�yo in N. sro3re-VCdL ism v. -7 l�� <br /> II. Type of Building(check all that apply) OCiry <br /> A I or'_Family Dwelling -Number of Bedrooms []Village _— <br /> ❑ Public'COrrunercial-Describe Use ®'Township Je &kOO a9 _ <br /> ❑Sure Owned Nearest Road <br /> Ale,; ( /Pc0. <br /> ID. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> C <br /> I 'u Nzw 2�i Replacement System 3 D Rzpiarement of 6 �� Addition m For ounty use <br /> S'stenn I Tank Only Existing Svstem <br /> B. <br /> 1.1 Check if Sanitary Permit Previously Issued <br /> Permit Number Daie Issued <br /> IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 Po Non-Pressurized In-Ground 210 Mound 47 0 Sand Filter 50❑ Constructed Weiland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48 Single Pass 51 ❑ Drip Line <br /> 45 'u At-Grade 46❑Aerobic Treamn nit Unit 49 Recirculating 30❑Other <br /> V. Dis ersal'Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Sod Application Percolation Rare System Elevation Final Grade <br /> Required Proposed Rare(Gals./Days/Sq.Ft.) (Min.flnch) Elevation <br /> Ora 6113 aelg . 7 — 9A' f (F6.5— I <br /> V1.Tank Info Capacity in Total Number Manufacture: Prefab Site Steel Fiber Plash:; <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tana — <br /> Septic or Holding Tann �0 /Goo 2 <br /> Dosing Chamber <br /> VII. Responsibility Statement- 1,the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> cHfl�zy ir/S 22SSsl 7(5- S66- 4157 <br /> lumber's Address(Street,City.Sure,Zip Code) <br /> 277 (oo 14w 35 EB , _<,4Sj_3 <br /> V,�,,U�L County/Department Use <br /> Ofily ly'Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing A ignature( o Scamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse j �c5o � /7 �¢ <br /> Determination `7D !� <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete pars(to the County only)for the system on paper not less than Blit x Il Inches in sue <br /> SBD-6398 (R. 05101) <br />