Laserfiche WebLink
' Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21 Wis.Adm. Code 201 W.Washington Ave. <br /> N iseonsin See reverse side for instructions for completing this application PO Box 7302 <br /> Department or commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> Attach cont fete tans to the coon co onl for the s stem on r not less than 8-I/2 x I 1 inches in size. state owned. <br /> 11.County State Sani P Number ❑ <br /> /Ir Elie 4 k if revision to previous application State Plan I.D.Number <br /> I,A licatlon Information-Please Print all Inform11 ation j) <br /> Property Owner Name Location: /V <br /> Property Location <br /> rrDI Lot 1/4/VEl/4 S S T3?,N <br /> Own s Mailing Address <br /> rOPublic/Connnercial <br /> R E• ST Block Number <br /> v� <br /> e Zip Code <br /> Subdivision Name or CSM Number <br /> 41fe of Building: (check one) <br /> 2 Family Dwelling-No.of Bedrooms: ❑City <br /> (describe use): ❑Village <br /> ❑ State-Owned 6XTown of <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) ares[ <br /> Me'A) L ❑New System 2. AReplacement 3. ❑Replacement of 4. ❑Addition to Parcel T�titerO n <br /> S stem <br /> B) Tank Onl Existin S stem y 11 Permit Number A Sand Permit was viousl issued Date Issued <br /> IV.Type of POWT System:(Check all that apply) <br /> 1Non-pressurized In-ground ❑Mound <br /> 13 Pressurized Sand Filter Constructed Wetland <br /> At- are In-ground El Holding Tank <br /> 13❑At- ade � ❑Single Pass ❑Drip Line <br /> Aerobic Treatment Unit ❑Recirculatin ❑Other; <br /> V.Dispersal/Treatment Area Information: El <br /> L.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grede <br /> 3 b b Required Proposed Rate(Gals./day/aq.fl.) (Min./inch) Blevation <br /> VI.Tank Capacity in ToEaI #ofq� <br /> Information Gallons Gallons Tanks Manufacturer Prefab Site Steel Fiber- Plastic <br /> New Existing Con- Con- glass <br /> Tanks Tanks trete strutted <br /> bo ig�7Y V ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement _ L _ <br /> I,the undersi ed assume res 'bili for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plum s Signature o stamps): MP/MPRS Nc. <br /> 4e(S Business Phone Number <br /> aQv r � ZZ S L 2 7� ,�- <br /> Plumber's Address(Street, ity,State, 6 a� <br /> Zip Code) ` <br /> VIII.C(1u1my I I partment se Only <br /> ❑Disapproved Sanitary Permit Fee eludes Groun water Date Issued <br /> pptoved ❑Owner Given Initial Adverse Surcharge Fee) ) Issuing Si ) <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: 1 <br /> SBD-6398 R07/00 <br /> D� <br /> RNF L <br /> 2pN��OUNC <br />