Laserfiche WebLink
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 <br /> `�SconSin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 ` <br /> Department of Commerce [privacy Law,s. 15.04(1)(m)) (Submit completed form to county if not xJ <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 84/2 x 11 inches in size. ]CO <br /> Cou Numhar <br /> State Sanitary Pe it Number ❑ heck' visiop to revious ap 'cation State Plan L D. <br /> rum <br /> I.Application Information-Please Print allInformation Location: <br /> Property Owner Name / Property Location <br /> 601-1) Q/s 1/4 1/4,s.2 T_7,N,R/f(or <br /> Property Owner's Mailing Address Lot Number Block,(Number <br /> / <br /> City,State Zip Code Phone Number Subdivision Name or CSM NumberG9,, <br /> Y37� 2GJ c + a <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> )tPublic/Commercial(describe use):– -6 a/ )+Gown of yl / <br /> ❑State-Owned ^u v <br /> Nearest Road <br /> Parcel Tax Numbers) �p d <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. eplacement 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 blMound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> I.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> yp a <br /> VII.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 /> Tanks I Tanks <br /> yea cl �Qod N0,reesc-a <br /> �r, (I00 — poo o�i�-�✓ ❑ ❑ ❑ ❑ <br /> III.R05sponsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> _!5%_' ., A-, �.✓7_ SYS��- <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater to Issued Issuing A ent 1gna (N s) <br /> Approved C3OwnerGiven Initial Adverse Surcharge Fee) C� v n <br /> Determination t U <br /> X.Conditions o p royal/Reasons for Disapproval: //)k <br /> SBD-6398(R.07/00) <br />