Laserfiche WebLink
(-MI74Y wS/orF /V; 30 <br /> Safety and Buildings Division County <br /> NVisconsin <br /> 201 W.Washington Ave.,P.O.Box 7162 SCAen-e <br /> Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 7 <br /> Sanitary Permit Application State Plan I.D.Number /� ) / <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 1 �Q 7 91 <br /> 5 91 <br /> may be used for secondary purposes Privacy Law,s I5.04(1)(m) Project Address(if different than mailing address) , ^ <br /> I. Application Information—Please Print All Information 3 g6 k i(S�rou t /�e�• lJ�l <br /> oZgS <br /> Property Owner's Name E f Ma Parcel# Lot# BIOCk# <br /> L n» I'lO revr Oo18 -4/14. 039eQ <br /> Property Owner's Mailing Address Property Location `�, 5 <br /> ISO& Netvfon ✓e .✓ 3� 5 <br /> City,State Zip Code Phone Number �•• _y4, Section /9 <br /> 1*4 k• //1/✓• _1W 79390 (circle) <br /> II.Type of Building(check all that apply) <br /> T N; R / Eor <br /> A I or 2 Family Dwelling-Number of Bedrooms aL )Subbdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> State Owned-Describe Use <br /> ❑City_❑Village ownship of _xe)tt` <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B• ❑ Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System; Check all that apply) <br /> ❑Non-Pressurized In-Ground X 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.Dia ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 `l 33a <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding—Tank 7S-O 7S0 <br /> Aerobic Treatmem Unit 17 <br /> Dosing Chamber 3'00 zw <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Rie:Ae /5/0 /terns ?..i.�..Q f/ d•01-5-ev-/ lis- a6b- 4/r7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ?7bo 05 3S webs��� ca/1 sy89� <br /> ?77 <br /> tment Use Onlsapproved Sanitary Permit Fee(includes Groundwater Dateissued Issuing t store tamps) <br /> Surcharge Fee) /wner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches In size <br /> SBD-6398 (R. 01/03) <br />