Laserfiche WebLink
Sanitary Permit Application Safety&Buildings Di <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washingui <br /> See reverse side for instructions for completing this application PO Box U <br /> isconsin personal information you provide may be used for secondary purposes Madison,WI 53707 0 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county i <br /> state o <br /> Attach complete plans to the county copy only)for the system,on paper not less than 8-1/2 x I 1 inches in size. j <br /> County State Sanitary Permit Number ❑C k if rev'sion to reviou)application State Plan 1.D.Nu er <br /> asp is <br /> LAPAicationInformatioi Please Print all Information Location: <br /> Property O/wrier Name Property Location / <br /> lR I u 1/4 1/4,S 6 T ,N, oa' j <br /> Property Owner's Mailing Address Lot Number Bbak-Mmn4ac <br /> 0 4t Av, Al E• 4 3 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 1►4M- 553 3_17-4- ✓ 2 43S <br /> II,Type of uilding: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms. Z ❑Village <br /> ❑ Public/Commercial(describe use): Town of��� <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. CMNew System 2. ❑ Replacement 3. ❑Replacement of 4. ❑ Addition to Parcel Tax Numbe(s) <br /> System Tank Only Existing System O 0 <br /> B) Permit Number Date Issued <br /> ElA Sanitary Permit was previously issued <br /> Iy.Type of POWT System: (Check all that apply) <br /> on-pressurized In-ground Cl Mound ❑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 /> I.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) - EI vation <br /> 300 (Poo 45- <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing Crete structed <br /> Tanks Tanks <br /> ptmc <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number r' <br /> LKrTIv/ <br /> umber's Address(Street,City State,Zip Co e) AF <br /> 2-7760 3S S4sg3 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary PermijkF�ee(Includes Groundwater Date Issued ' Issuing A e ' Si r ps) <br /> h <br /> Approved ❑Owner Given Initial Adverse Surcharge Feelk �^ 1� D/ <br /> Determination ------��'''' V l/ <br /> IY.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />