Laserfiche WebLink
Misconsin Sanitary Permit Application Safety&Buildings DivisionIn accord witComm83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> Department of Commerce Personal information you provide may be used for secondary purposes <br /> Madison,WI 53707-7302 <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> Attach com tete fans to the coon co onl for the system o a er not less than 8-1/2 x I 1 inches in size. state owned. <br /> County & State Sanita Permit Number ❑Check i rev' 'on to vious application State Plan I.D.Number <br /> I.Application Information-Please Print all Informat # <br /> Prope Owner Name Location: <br /> Property Loc�ati�on <br /> Property Owner's Mailing Address /l1[�/1/4/1$✓1/4,S T T 46,N,R/6E or W <br /> 2 ?/� / Lot Number Block Number <br /> PK�Iublic/Conmncrcial <br /> ,Statee W �f� Zip Code <br /> Phone Number 6 Subdivision Name or CSM Number <br /> r 4/ 3o iS �7z S lsiz <br /> ype of Building: (check one) <br /> or 2 Family Dwelling-No.of Bedrooms: _ ❑City <br /> (describe use): ❑Village <br /> ❑ State-Owned 6l(Town of <br /> III. ©a <br /> Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road � y ss, <br /> ±B) <br /> f New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numbe <br /> System Tank OnlyExistingSystem <br /> PernitNumber La !a1 1 Permit was previouslyissued Date Issued <br /> IV.Type of POWT System:(Check all that apply) <br /> RrNon-pressurized In-ground ❑Mound <br /> ❑Pressurized In-ground ❑Sand Filter ❑Constructed Wetland <br /> ❑At-grade ❑Holding Tank ❑Single Pass ❑Drip Line ) <br /> V.Dis ersareatment Area Information: ❑Aerobic Treatment Unit ❑Recirculating13 Other: <br /> 1 <br /> UT' <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dis ersal Area <br /> Required P 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> / 4 Proposed Rate(Gals./day/sq.ft.) (Min./inch) <br /> `7'J Q .Q�S ?��,„n / Tn/ p; Z Elevation <br /> VI.Tank Capacity in Total #of ` T antic <br /> Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks <br /> New Existing Con- Con- glass <br /> Tanks Tanks crete structed <br /> X "'Poo / Cv,e sir ° El ❑ ❑ <br /> ° ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersi ned,assume res onsibili for installation of the POWTS shown on the attached plans. <br /> Flu is Name riaAZI�Z_j <br /> Plumb signs no <br /> g ps): rim <br /> No. TBu;s;i;nt!: Phane Number <br /> / 6SS s 6��-2sea <br /> Plumber's AdJr <br /> dress(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) Issu' g Agent Signature(No stamps) <br /> 2Determination 5- <br /> X.Conditions <br /> Iof Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />