Laserfiche WebLink
Safety and Buildings Division County <br /> 201 W. Washington Ave..P.O. Box 7162 U rN <br /> isconsin Madmen'WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce ( )260r3151 '55 1 1r' <br /> Sanitary Permit Application State P . Number <br /> In accord with Comm 53-21.W is.Adm.Code,personal Information you provide l <br /> my be used for secondary purposes Privacy Law,s15.04(Ixm) Project Address(if different than mailing address) P \ <br /> I. Application Information-Please Print All information 3� 3 939 1 <br /> of () <br /> Property Owner's Name Parcel# — # S�j Block# Jc-) <br /> - *1.0L// <br /> 07-012-Z-x-1513—5- f�-27o-abSt� <br /> 0121 3006600 <br /> Property Owner's Ma fling Address Property Location <br /> 7 At'j 6-4- %, 16,Section _3 <br /> City,State Zip Code Phone Number <br /> �t, alr 0" 6Y6y3o �i5 zsg -y135 ���.4(ccircle a <br /> II.Type of Building(check all that apply) T y� N; R�_E o� <br /> 1 or 2 Family Dwelling-Number of Bedromrs Z Subdivision Name I/VI,.1I CSM Number/ <br /> LlPublic/Commercial-Describe Use16P 't IAV '� V•/ V. <br /> ❑State Owned-Describe Use ❑City_❑Village Wownship of The <br /> III.Type of Permit: (Check only one box on line A. Complete lice B if applicable) <br /> A. ❑ New System Replacement System ❑Treamaent/Holding Tank Replacement Only ❑ Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision 11 Change of Q Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Phunber Owner <br /> M Type of POWTS System: (Check all that ) <br /> Non-Pressurized In-Ground ❑ Mound Z 24 in. of suitable soil Q Mound < 24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter <br /> ❑ Constructed Wetland ❑ Pressurized In-Ground ❑ Holding Tank ❑Pet Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter <br /> ❑ Recirculating Synthetic Media Filer ❑Leaching Chamber Q Drip Lim ❑Gmvd-fess Pipe Q Other(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Raw(gpdsf) Dispersal Area Requted(st) Dispersal Area Proposed(s0 System Elevation <br /> 3� *7 92 ya 95 0 <br /> VI. Tank Info Gpacity in Taal Number Mmarfacoaer Prefab Sire Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> NewExiting <br /> TaNrs Tanks <br /> Septic or Holding Tank / WC. <br /> Aerobic Tteamem Unit <br /> Dosing Clamber <br /> VII.Responsibility Statement- I,the undersigned,awe respamMTty fne hrataBdiaa of the POW7'S shawa an the attached plans. <br /> Plu 's Name(Pr�in t) Pire.Sig_n/ave MP/MPRS Number Business Phone Number <br /> �/ / 95 /S)�W 9076 <br /> Plumber's Address(Street ,City,S Zip Code) <br /> 71AZ6 Zl s � W e�s�d l✓; 5 4 <br /> VIII.Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Dat.Issued Issuin nt Signamr o Stamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Reason for Dentia) <br /> IX. Conditions of Approval/Reasons four Disapproval <br /> 80TK,5s g 1 k 2 5 Vow Pµlyr� <br /> ave USeR as ax I( as Pew Bof,4i a <( by 444 7511j.hr OCj _ 6 2011 <br /> gURNEV C GUtM <br /> Attach complete Flaw(to the Caunty only)for Oe system apa m pane�tban airs:Il kWh"is arse <br /> SBD-6398 (R. 01/03) <br />