Laserfiche WebLink
Safety and Buildings Uiviston county R <br /> r r 201 W. Washington Ave.,P.O. Box 7162 Ih ✓1 c. <br /> ►seansin Madison, WI 53707-7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary Permit Number (' \ <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if R !1 l.,.P�/� 7� <br /> may be used for sero purposes PrivacyLaw 15. 1 m Revision lgl`1 t4 <br /> I. Application Information-Please Print All Information 4 State Plan I.D.Number AS <br /> Property Owner's Name <br /> PA;cle Number <br /> N� V <br /> Property Owner's Mailing)Address Q !// <br /> Property ,pa <br /> aaN6t],ty/V�I. 14 S :Zg Tye N.R/9 i <br /> City,State ', !! Zip Code Phone Number Lot Number Bleck Number <br /> tie`j j�( W� 7 y py Z Subdivision Namc CSM Numbe <br /> 11.Type of Building(check all that apply) 7 J J ocity <br /> or 2 Family Dwelling-Number of Bedrooms ge <br /> ❑Public/Commercial-Describe Use ❑VillaOVUlaship Scn-{�- <br /> ❑State Owned 9TownNearest Road <br /> `-,J f_, <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B i applicabla:) <br /> A' i W_Ne 2 ❑ Replacement System 3 ❑ Replacement of 6 Q Addition to For County use <br /> System Tank Ordy Exisl S stem <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 4-Non-Pressurized In-Ground 2113 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./DayslSq.Ft.) (Min./Inch) Elevation <br /> G q l If .2 '12- iso P1/- q ?0 <br /> VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Sieel Fiber PI ;[ic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Talc ADO - /0()() W1 ,t1 e 5.e` x <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the un rsigned,assume responsibility for installation of the POWTS shown on the attached pkins. <br /> PI u ber's Name(Print) Plu is S}}'ggna��ture PRS Number Business Phon:Number <br /> u� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 01 <br /> VIII. ount /De artment Use 00 <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing ni gnature o San ps) <br /> Surcharge Fee) <br /> El Given Initial Adverse Cdr[ <br /> Determination <br /> UI. Conditions of ApprovaUReasons for Disapproval <br /> 4� <br /> I <br /> JUL - 2 2 <br /> COUNTY <br /> Attach complete plans(to the County only)for the system on paper not less than al0?x t l t to <br /> L 1 siaywllgl" --- <br /> SBD-6398 (R. 05/01) <br />