Laserfiche WebLink
Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> ` See reverse side for instructions for completing this application PO Box 7302 <br /> lisconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned.) <br /> Attach complete plans(to the county copy on for the system,on paper not less than 8-1/2 x I inches in size. <br /> Coun State anitary Penn i�t�Nugtber ❑Check if rern to preious application State Plan 1.D Number <br /> �,�Ne (�� -ICN �X3 9�F9Z3 <br /> I.Application Information-Please Print all Information Location: <br /> Property lhvner Name ////�i)� Property Location T ��II 0 4,1 1/4 1/4,S TVO,N,R/E(or LY <br /> Property is Mailing Address <br /> Lot Number Block Number U <br /> /6/ o D� &L-S+ 1 <br /> City,State Zip Code Phone Number SnbdiMisiepAiame or CSM Number N <br /> Ea -+� s77ti s5/�z ( ) 1� � o t'l <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms:_ ❑Village <br /> ❑Public/Commercial(describe use):_ 'Town of <br /> ❑State-Owned -j G07�z— <br /> Nearest rd <br /> _/ 31-25/ <br /> Parcel Tax Nu ber(s O O <br /> III.Type of Permit: (Check only one box on line A. Check e B if applicable) <br /> box on lin <br /> AT <br /> 1. ❑New 2. eplacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Dale Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground U(Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑ Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(GalsJday/sq.ft.) (Min./inch) p Elevation <br /> 3c,e> -3 30 / / / 7i S <br /> 1� 3 <br /> VII.Tank Capacity in Total #of ManufacturerPrefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> S Q fic 7S-2:) 7s o ❑ ❑ ❑ ❑ <br /> ver! o0 5'a a ❑ ❑ 11 <br /> Resp nsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) // f/ Plumber's Signature(n ps): MP/MP"No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> / ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin Sign o stamps) <br /> M Approved ❑Owner Given Initial Adverse Surcharge Fee) �j �J <br /> Determination o2J�� �7,3 � 03 <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R-07/00) <br />