Laserfiche WebLink
Sanitary Permit A11 <br /> on <br /> In accord with Comm 83.2 1, W i�sl Adm Code <br /> PeSafety&Buildings D i <br /> iseonsin See reverse side for instructions for completing this application 201 W. Washingt <br /> Department of Commerce rsonal information you provide may be used for seconds <br /> PO Bo. <br /> (Privacy Law,s. 15.04(1)(m)] secondary purposes Madison,WI 5370 <br /> Attach com tete tans to the coon co o (Submit completed form to county 'f t <br /> County nl for the s stem,on a er t less than 1/2 x I l me es in size. state o <br /> State Sanit11 8- <br /> Pe it u 64r <br /> �'1 k this' n to rev'ous plication State Plan[,D.Number <br /> I. ication Information-Please Print all Informaot'i_o— <br /> n <br /> Property Owner Name <br /> �. I Location: <br /> /� <br /> OL15O Property Location <br /> Property Owner's Mailing Address rc <br /> 1711 i/4 1/4.S •JT ,N, o <br /> Lot Number ,gam <br /> City,State /^ <br /> Zip Code Phone Number `�i• L <br /> MN 550 82 ^ p Sub ivision Name or C Jf Number <br /> I .Type of Building: (check one) )43 1' �2Q7 u — g <br /> 1 or 2 Family Dwelling-No.of Bedrooms : 3 <br /> ❑ Public/Commercial(describe use): ❑City <br /> 13State-OwnedVillage <br /> Town of <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road Tncksw <br /> A) I. ❑New System 2. replacement 3. ❑Replacement of 4. SH'p� <br /> B) S stem Tank Onl ❑Existing <br /> °°t° Parcel Tax Nu ber(s) , <br /> Existin System QI �►35- OS <br /> ❑A Sanita Permit was reviousl issued Permit Number �O <br /> • Type of POWT System: (Check all that a I Date issued <br /> Non-pressurized In-ground pP y) <br /> ❑Pressurized In-ground ❑ Mound ❑Sand Filter <br /> ❑At- ade ❑Holding Tank ❑Constructed Wetland <br /> ❑Aerobic Treatment Unit ❑Single Pass <br /> V. Dis ersaL/Treatment Area Information: ❑ Recirculatin ❑Ot e Line <br /> I.Design Flow ❑Other: <br /> (gPd) Z.Dispersal Area 3.Dispersal Area <br /> Required Proposed 4.Soil Application 5.Percolation Rate 6.System Elevation <br /> 4� / 4 3 Rate(Gals./day/sq.ft.) (Min./inch) 7.Final Grade <br /> t0 (04 p ,`� �� / Elevation <br /> VI.Tank Capacity in 7r' G 96. 6 <br /> Information Total tt of Manufacturer <br /> Gallons Gallons Tanks Prefab Site Steel Fiber- Plastic <br /> New Existing Con- Con- <br /> sC' Tanks Tanks crete structed glass <br /> IC loop Loos I ❑ ❑ ❑ <br /> (0010 <br /> VII.Responsibility Statement ❑ ❑ ❑ i ❑ <br /> I,the u am ( ned,assume res onsibili for installation of the POWTS shown on the attached tans. <br /> Plumber's Name(print) Plumber's Signature(no stamps): <br /> MP/MF No. <br /> ��J �+ Business Phone Number <br /> umber's Address(Street,City State,Zip Coe 2.2% `�� !" <br /> 2.77/0 ) J� - /S7 <br /> 3S WE85TE1� WI. 54893 - <br /> VIII. County/Department Use Only <br /> oved <br /> ❑Disapproved <br /> Sanita P <br /> rge Fee(Includes Groundwater <br /> ing <br /> (���n\f Date sued IssuAge t gnatu <br /> ❑Owner Given Initial Adverse S hae <br /> Determination /' ,s3a <br /> IX. Conditions of Approval/Reasons for Disapproval: o(,Q CLJ <br /> SBD-6398 R071100 <br />