Laserfiche WebLink
Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 uroezL <br /> Visconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 '�fo)37,36hla /d <br /> Sanitary Permit Application State Plan I.D..Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sI5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information _Dd /i'�.•/I� Loire,L <br /> Property Owner's Name Parcel# Lot# Block# <br /> Property Owner's Mailing Address T Property Locaattionq 36 <br /> �''" 7a �, AW <br /> /., Section <br /> City,State Zip Code Phone Number <br /> vele on <br /> 7' `7 T��N; R_JE or <br /> II.T pe of Building(check all t at apply) ^''� <br /> 1 or 2 Family Dwelling-Number of Bedrooms 1l Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use V/R F_59 / <br /> El State Owned-Describe Use ❑City_❑Village Township of .5/c- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> Non-Pressurized In-Ground 11 Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ElAt-Grade El Single Pass Sand Filter ❑ <br /> Constructed Weiland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> SeD �1a9 el3 ) ��. <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks rs�� <br /> Septic or Holding Tank /DOD <br /> Aerobic Treatment Unit �V <br /> Dosing Chamber <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' Si atu MP/MPRS Number Business Phone Number <br /> Wdliam hA-WmAq,t� ��D 318 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> W Igqq Hui - (cam S�1��5 <br /> II.County/Department bse Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date issued issuing Agent Signature(No Stamps) <br /> ❑ Surcharge Fee) �f',; , <br /> O� <br /> Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 8112 x 11 Inches in sin <br /> SBD-6398 (R. 01/03) <br />