Laserfiche WebLink
Safety and Buildings Division County <br /> 201 W. Washington Ave., P.O. Box 7162 tw a of V014-&Nvi4constn Madison, WI 53707 -7162 Site Address <br /> Department of Commerce a <br /> Sanitary Permit Application SanitaryPermit NumbJr <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision <br /> may be used for second purposes PrivacyLaw,sl5.04(1)(m) + L:,44 <br /> I. Application Information-Please Print All Information State Plan I.D. Number �w!" <br /> Property Owner's Name Parcel Number <br /> Cara to 01SOn D?8- j 13 -03-OG3 <br /> Property Owner's Mailing Address Property Location 66v-E.L�-s <br /> 6-j o ceom 0^ 'A ti;S 3Z/ T 190 N,R 1 w <br /> City,State Zip Code Phone Number Lot Number <br /> ber Block Number <br /> Subdivision Name CSM Number <br /> Mou"d$ View Aq Al rs/l ji. 763- 7?4- YEAS;, (2son54 <br /> H.Type of Building(check all that apply) ❑City <br /> A I or 2 Family Dwelling-Number of Bedrooms et- ❑Village <br /> ❑ Public/Commercial-Describe Use XTownship .S<07'L71- <br /> ❑State Owned Nearest Road <br /> Ill.Type of Permit: (Check only one box on line A (numbering scheme foE,internal use). Complete line B if applicable) <br /> t Er New 2 ❑ Replacement System 1 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> Sys in Tank Only Existim System <br /> B. ❑ Check if Sanitary Permit Previously Issued Pemtit Number Date Issued <br /> IV.Type of Permit: (Check ail that apply)(numbering scheme is for internal rue) <br /> 44 iel Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Weiland <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 /> 3cp `-I/- q 'et 3.4, -7 — 97,D `?9.p <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks I Tanks <br /> Septic or Holding Tank too <br /> Dosing Chamber O <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MPIMPRS Number Business Phone Number <br /> 6j►oev »✓s R� e 22.58 s 1 115 46- 4K_7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 27-7 (o o }-}w 35 , _54-513 <br /> VIII. County!De artment Use Oifily <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing t Signam o Stamps) <br /> li( Surcharge Fee) 250 <br /> -� <br /> 0 <br /> 11 Owner Given Initial Adverse 41 /50"' 2rJ�r04 ow <br /> Determination O� v J <br /> nvwy <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 Inches in size <br /> SBD-6398 (R. 05101) <br />