Laserfiche WebLink
,t�, 5: & �ev,s,�� ��,t�X st/'n'5 <br /> Sanitary Permit Apple <br /> n Safety&Buildings Division <br /> 201 W.Washington Ave. <br /> In accord with Comm 83.21,WisCode PO Box 7302 <br /> �� See reverse side for instructions for compis application Madison,WI 53707-7302 <br /> IMSCOnS�n Personal information you provide may be uscondary purposes (Submit completed form to county if not <br /> Department of Commerce (Privacy Law,s. 15.04(1 <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Permit Number ❑Check if revision to previous application State Plan I.D.Number <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> � 1/4 1/4,S T_&,N,ROE(or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> DO / � � f <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 1\61e-r f5 arr 'S"Y6 -3 ( > U <br /> II.Type of Building: (check one) ❑city <br /> ❑Village <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms:�_ ZTown of _ <br /> )i�Public/Cornmercial(describe use):_ '(/' /� <br /> ❑State-Owned L'.� 'o <br /> Nearest Road qb( <br /> Parcel Tax Num is)In (f�oT/ <br /> o <br /> ` 1�,�b <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. ,Replacement 3. ❑Replacement of 4. 5. 6. 1:1 Addition to <br /> System System Tank Only Existing System <br /> B) PermitNumber DateI ued <br /> A Sanitary Permit was previously issued c;z s 3 Ci I 3c'q3— <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground Mound ❑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 /> 1.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 /> 00 foo �a/ • 7 1 <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons To <br /> Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> A ❑ ❑ ❑ ❑ <br /> c Xi C sO 7:5 <br /> 5617 — SOn Ijr jz ❑ ❑ ❑ ❑ <br /> -VI41.Responsibility 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 /> Plum is Address(Street,City,State,Zip Code) <br /> 'r�� <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fe ncludes Groundwater Date sued Issuing t Sig s) <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee) J6 <br /> Determination / <br /> X.Conditions of A provM/Reasons for Disapproval: <br /> /7 <br /> 5 1J e xis n7n� <br /> SBD-6398(R.07/00) <br />