Laserfiche WebLink
S:a, <br /> Buildings Division County 1/ <br /> 201 W. gton Ave.,P.O.Box 7162 (I�/V�/ <br /> INAisconsin Wl 53707-7162 Sanitary Permit Number(to be fillell in by COJ8)266-3151 X ) <br /> Department of Commerce <br /> State Plan LD.Numbs <br /> Sanitary Permit Application lei <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl 5.04l Hm) Project Address(if different than mailiinng address) 1 <br /> 1. Application Information-Please Print All Information /0 OL <br /> �- +c'/ /'r1r__rh 1 ll <br /> Property Owner's Name Parcel# Lot# 7Block# <br /> esu waver � X-PREM; WIRE t1c) 450 ii- 1/00) <br /> Property Owner's Mailing Address Property Location <br /> _'/., _Y., Section 13 <br /> Fublic/Commercial <br /> Zip Code Phone Number <br /> //'' "zirclep" <br /> ng(check all that apply) <br /> Su vision Name CSM Number <br /> elling-Number of Bedrooms <br /> ial-Describe Use r <br /> ❑State Owned-Describe Use ❑CiTy_❑Village Township of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)A. (fN'ew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System&0/0 0 <br /> B. ❑ Permit Renewal El Permit Revision El Change of [I Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.T e of POWTS S stem: Check all that-1y) <br /> I(Non-Pressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dis ersaVfreatment Area Information: <br /> Design Flow(gpd) Design Soilllie ation Rate(gpdst) DispersalAreaRequired(st) Dispersal r97?6 <br /> Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total Number /7J lAManufacturer !/ Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank O?OC) LV <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Pill 's Name(Print Plu 's SignaNre MP/MPRS Number Business Phone Number <br /> Toff 144 � i �95y �� 6-Pv7o <br /> Plumber's Address(Streel,City,State,Zip Code <br /> 272Zo 5q w, <br /> VII Count /De artment Use Oul <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issui A 1.Signatu o Stamps) <br /> Approved ❑ Disapproved Surcharge Fee) 'J, 11,/ <br /> ❑ Owner Given Reason for Denial 4 3255 `AV7 �f <br /> IX.Conditions of Approval/$asaewa-far13risapproo8l <br /> NJ(Cs Parcel Con5tsE3 oL Tw /ars (SD 4 Sl) Cs. bmvl <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in sire <br /> SBD-6398 (R. 01/03) <br />