Laserfiche WebLink
Safety and Buildings utvision t:ounty/� <br /> � ` <br /> ON 201 W. Washington Ave., P.O. Box 7162 ?2-a -fit e fi' <br /> `wiScOnsin Madison, WI 53707-7162 Site Address <br /> Department of Commerce S. e-6sG Lxv <br /> Sanitary Permit Application Sanitary Permit Number 90 <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you providel 02 <br /> may be used for second ses PrivacyLaw 15. 1)(m ❑ Check if Revision tJ <br /> I. Application Information-Please Print All Information ) State Plan 1.D.Number <br /> Property Owner's Name Parcel Number <br /> Derv- F* . t"f 01,t,- 4lj -03-$O(J <br /> Property Owner's Mailing Address Property Location 6OVt,(,r I A <br /> ;l 7539 JefFries RdP tf 'A;S 13 T 4D N,R/S' ` <br /> City,Stan Zip Code Phone Number Lot Number Blcck:lumber <br /> Subdivision Name CSM Numbe <br /> Welv><r, ct, gr lis- sb/r- g�36 <br /> II.Type of Building(check all that apply) ❑City _ <br /> 9 1 or 2 Family Dwelling-Number of Bedrooms <br /> ❑Village _ <br /> ❑Public/Commercial-Describe Use <br /> gTownship Jt?Gk„forl <br /> ❑State Owned Nearest Road <br /> ,S. 8w5'.r <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal nue). Complete line B if applicable) <br /> A. 1 .kr New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> Sys m TankOnfy I Existing S stem <br /> B• ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 VNon-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Wedand <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./inch) Elevation <br /> 36O 4�y 43f ,7 — sd. 96. o <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Sietl Fiber P►;,;tic <br /> Gallons Gallon of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank Rae <br /> Dosing Chamber <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached phis. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phon:Number <br /> /SrC/C /710 .E'irS / L-o1S"�'S`/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 77Go h'u 3s C c%e 6s�r� L tl?— s�893 <br /> VUL County/De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing t Signature tali Ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse � 2✓,l•sem � � col(, <br /> Detetminadon ((/J'•'''� T <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Artach complete plain(to The County only)for the system on paper not less than 81/2 c 11 inches in size <br /> SBD-6398 (R. 05/01) <br />