Laserfiche WebLink
4*- .3,7131 ­5'�;2P-.lex-) <br /> ` Safety and Buildings Division County <br /> T201 W. Washington Ave., P.O. Box 7162 wj-avdfiseonsinMadison,WI 53707 -7162 Site Address <br /> Department of Commerce1�2 <br /> Sanitary Permit Application Sanitary ertni[Number <br /> In accord with Comm 83.21,Wis.Adm. Code,personal information you provide <br /> Check if Revision <br /> may be used for secondary purposes Privacy Law,sl5. 1 m) ❑ /tea 3� ( 1 I <br /> I. Application Information-Please Print All Informatio State Plan I.D. Number / <br /> i <br /> Property Owns Name Parcel Number <br /> of —0%o7- a3-1 o <br /> Property Owner's Mailing Address Property Location <br /> p � <br /> 51 (/45W 'C L % ti;S 7 T N,R <br /> City,State Zip Code Phone NumberLot umber Block Number <br /> a <br /> Subdivision Name CSM Number <br /> r eji Mw S5`ii6 ,ysi eye-aiz <br /> H.Type of Building(check all that apply) 2 []city <br /> 1 or 2 Family Dwelling-Number of Bedrooms 3 ❑Village <br /> ❑ Public/Commercial-Describe Use XTownship f�^3 <br /> ❑State Owned Nearest Road <br /> 5y� rrr dk i <br /> I11.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. 1 9 New 2 11Replacement System 3 ❑ Replacement of 6 ElAddition to For County use � <br /> System Tank Only Existing System <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 Z Non-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Constructed Wetland <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 /> y5o W 5 9�s �7,� <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 Tanks <br /> Septic or Holding Tank 0170 Im00 ( YP2M/�1� <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> � rev ,l✓s - z�s$s i 7�s- S(6- 44s-7 <br /> lumber's Address(Street,City,State,Zip Code) <br /> 27-7 o f4w 315 aE �4-513 <br /> VIII. CountyDepartment Use Ofily <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuing A ent Signature o ta ps) j <br /> Approved ❑ Disapproved S\ charge Fee) <br /> ❑ Owner Given Initial Adverse W --2 �Q a <br /> Determination V �C <br /> IX. Co ditions of pproval/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 />