Laserfiche WebLink
-Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Waazhington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> Aisconsin personal information you provide may be cued for secondary purposes Madison,WI 53707-7302 <br /> Oep9rtment or Commerce [Privacy Law,s. IS 04(1)(m)] (Submit completed form to county if not <br /> state owned.) n , <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. w <br /> CountyState Sanitary P i N if in to previo plication State Plan 1.D.Number <br /> I.Application Information-Please Print all Information Location: <br /> Propertyy+ <br /> nyOwner Name Property Location 4FT <br /> �/ <br /> (,�(� 1 1/4 1/4,S T70,N,EY <br /> Property Owner's Mailing Address Lot umber Block Number <br /> V`E.. to l 5r <br /> 'icy,State Zip Code Phone Number Subdivision Name or CSM Number <br /> VZ 5-4L72a - <br /> H Type of Bui ing: (check one) a City <br /> 7� 1 or 2 Family Dwelling—No.of Bedrooms:_ ❑village a�� <br /> 3 Public(Commercial(describe use): PKTown of <br /> 7 State-owned 111 <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) I. )(New System 2. ❑ Replacement 3. ❑ Replacement of 4. ❑Addition to Parcel N'um/bers) 00 <br /> Svstem Tank Only Existine Svstem <br /> B) ClPenni[Numbcr Dale issued <br /> A Sanitary Permit was ormousiv issued <br /> V.Type of POWT System: (Check all that apply) <br /> cion-pressurized In-ground ❑ Mound ❑Sand Filter ❑ Constructed Wetland <br /> 7 Pressurized In-ground ❑ Holding Tank ❑Single Pass ❑ Drip Line <br /> 7 At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> i Dispersal/Treatment Area Information: <br /> Design Flow(gpd) 2.DispersalArea 3.Dispersal Area 4.Sod Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft) (Min./inch) Elevation <br /> 7. — �3^ s' fT/Oo <br /> Z Tank Capacity in Total of Manufacturer Prefab Site Steel Fiber- Plastic <br /> aformation Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> ❑ ❑ ❑ ❑ ❑ <br /> -H Responsibility Statement <br /> I,the undersizried,assume responsibility for i io f shown on the attached plans. <br /> umbers Name(print) Plumber igno s ps): MP/MPRS No. Business Phone Number <br /> John Solofra #223779 715-376-2278 <br /> umbers Address(Street,City,State,Zip Code) <br /> PO Box 161; Gordon, WI 548 8 <br /> III County/Department Use Only <br /> ❑Disapproved Sanitary Permit Jee(Includes Groundwater Date Issue Issuing a Si re s) <br /> roved C3Owner Given Initial Adverse Surcharge Fee �` U / <br /> Determination C <br /> Conditions of Approval Reasons for Disapproval: �� <br /> IAUG — 2 202 <br /> BU <br /> ZONING NTY <br />