Laserfiche WebLink
Safety and Buildings Division County <br /> �` 201 W. Washington Ave., P.O. Box 7162 f3U-rTLf- <br /> fisevnsin I Madison, WI 53;07 -7162 Site.address <br /> 9epartment of Commerce <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 33.21,Wis. Adm. Code, personal information you provide <br /> may be used for secondary o i Check if Revision /�j.�1 7 <br /> —_ urttoscs Privacy Law. ;IS.i�(1)im) CC//✓✓ <br /> I. application Information- Please Print All Information State Plan I.D. Numbe- <br /> Property Owner's Name Parcel Number <br /> ei a 2 X120 7 0 /00 <br /> Property Owner's Mailing Address <br /> Property Lacadon <br /> Cay, State 1 ..lp C,x!e 7 T yp N R <br /> P..unc Number Lot Lumber Block Numce- <br /> L 6t3L 2- <br /> Subdivision Name CSM Number <br /> II Type of Building(check all that apply) <br /> -C.-Lyr 1 or'-Family Dwelling-Number of 3edrooms Z <br /> _ Aablic�Catnmercial-Describe Use _,Village <br /> '$Township C3ac1 � <br /> State Owned <br /> Nearest Road <br /> I <br /> z� , ( <br /> III Type of Permit. (Check only one box on lute A (numbering scheme for internal use). Complete line B if applicable) <br /> A. I V New 2 1_,' Replacement System 13 Replacement of 6 Addition to For County use <br /> System ! Tank Oniv Existing System <br /> 3• j ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issue-- <br /> IV. <br /> ssuedIV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> i <br /> 44} Von-Pressurized In-Ground 2111 Mound 47 J Sand Filter 50 Constructed Wetland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank48-1 Single Pass 51 '� Drip Line <br /> 45 J At-Glade 46 U Aerobic Treatment Unit 49'i Recirculating 30 F Other <br /> V. Dispersal/Treatment Area Information: <br /> 1 Design clow(gpd) Dispersal Area Dispersal Area Sou Application Percolation Rate System EievaEcn Firm _rode <br /> Required I Proposed Pam(Gals.,'Days/Sq.Ft.) 'Mia./Inch) Eleva^.ea <br /> . 67 IF,2_1� <br /> VI. Tank Info Capacity in Total I Number Manufacmrer 1 Pre,ab1 Site Steel 1 F ice: ?!asci:: <br /> Gallons Gallons of Tanks Conc ete Construc:ed i Glass <br /> 4ew Ezisrsg <br /> Tanis Tanks <br /> �.' <br /> Septic or Holding Tank I �OwM _ ,OO 1 <br /> Dosing Chanter _ <br /> li <br /> VII. Responsibility Statement- 1,the undersigned, assume responsibility for installation of the PONNTS shown on the attached plans. <br /> Plumber's Name(Print) ?!umber';Signore MP/%IPRS Numbdr Business ?tone Nur..xr <br /> P!umcer s Addmss(Street.Cary, Stare, Z;.0,Code) t — <br /> 2.77 loo 14w-1 <br /> VIII. County/Department Use 011iv � <br /> pro+r anuari Ptrm¢F-_ ,..duds Greued,Hata' Date Is;ccd I niin;; .- _ .; Signa2.rc ame <br /> - p j Disapproved . <br /> I <br /> Surharge . -. <br /> Owre:Given(nicai Adverse I <br /> Determirar.on <br /> ! <br /> Lt. Conditions of ApprovaUReasons for Disapproval -- —'- ----- <br /> 1 <br /> Attach complete plant to the Cnuur,onl.a or the xystem nn paper not fess than 81;]c 11 inches in Siz^ <br /> SBD-6393 (R. 0101) <br />