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 /> isconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of commerce Submit completed form t0 county if not <br /> [Privacy Law,s. I5.04(I)(m)] ( P tY <br /> state owned.) 1 <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. <br /> County I AjoSSani ary Permit Number Chec:X if r vision to pre ious application State Plan 1.D.Number <br /> lor tat �i <br /> I.ApI111cation Information-Please Print all Informatio Location: <br /> Property Owner Name <br /> A ��t Property Location ,, <br /> AKEUA1G 1/4 1/4,S * T`AA4 N A or <br /> Prope4 Owner's Mailing Address Lot Number Block Number <br /> g20 R. APE # IDS q d/o <br /> City,State I Zip Code Phone Number Subdivision Name or CSM Number <br /> 1S )3E6-.'%9(o /'SrAV. <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑ Public/Commercial(describe use): FmTowri of <br /> ❑ State-Owned /sjt <br /> I1I.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> a <br /> A) 1. XNew System 2. ❑ Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Only Existing System Q 0/ <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> Non-pressurized In-ground ❑ 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 /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(GalsJday/sq.ft.) (Min./inch) Elevation <br /> 450 643 X48 q3. S- q4�s <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 /> _515pne to 00 loos I NDRwEst;o ° ° ° ° <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumbers Name(print) Plumber's Signature(no stamps): MP/MPRS No. r Business Phone Number <br /> Nrir+c,V �S�J S ��7 <br /> umbers Address(Street,Ci ry State,Zip Co e) <br /> 2-7760 35' 05a WI. -546o q3 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date ssue - Issuing -gent Si atEamps) <br /> tpproved El Owner Given Initial Adverse Surcharge Fee) ;2 ^,,r �/� D� <br /> '� `l Determination W <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />