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 <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 ❑ e k if revi ion to previous ap lication State Plan I.D.Number <br /> ylW 975 /o/ ?211 06 <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name r Property Location <br /> O!? nJ �/-/ G/L go+J 1/4SE1/4,S 3� 3 .N.R!E(orlciW <br /> Property Owner's Mailing Address // / Lot Number Block Number <br /> -2- qF 5 S a4� ,- dl lr� <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> II.Type of Buil mg: (check one) ❑City <br /> -t or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ own of / <br /> ❑State-Owned <br /> Nearest Road / c 114r7r <br /> Gy^Jc/ cis S <br /> Pazcel Tax Num r(s)av /Q_�� <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Y <br /> A) 1. w 2. ❑Replacement 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 /> 11 �t <br /> Non-pressurized In-ground Wund ❑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 Rate7119 <br /> ystem Elevation 7.Final Grade <br /> Required Proposed Rate(GalsJday/sq.ft.) (Min./inch) Elevation <br /> � ad pi2 Df) <br /> VII.Tank CapacHing <br /> Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information GallGallons Tanks Con- Con- glass <br /> New crete structed <br /> / Tanks <br /> s 2 Tic ���0 75 O ❑ ❑ ❑ ❑ <br /> AY 00 :6u ❑ ❑ ❑ ❑ <br /> VIII.Resp nsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name int) Plumber's Signature no stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> lea X - <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin gent Signature(No stamps) <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee) 7 <br /> Determination / ' ri <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(K 07/00) <br />