Laserfiche WebLink
Safety and Buildings Division County <br /> Visconsin <br /> 201 W. Washington Ave., P.O. Box 7162 y r N Madison, WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 49 <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis. Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law, 05.04(1)(m) Project Address(if different than mailing address) W <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel X Lot K Block N <br /> �04) 94i►7Cr ao 9/S6 e / -200 ,- <br /> Property Owner's Ma iling Address 1 Property Location 41,v <br /> gp `� C Am e�6T L/ <br /> City,State Zip Code Phone Number u,_!4,Section <br /> L d Q u N 4 k'e�e c.v T 5_357y-7 b of gV7- (circle ore) <br /> 11.. Type of Building (check all that apply) T � N; R�E or® <br /> tat 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name L CSM Number <br /> 11Public/Commercial-Describe Use ' P/4 f,off L 4G IC ,s1/1k e C <br /> ❑State Owned-Describe Use ❑Ci 8 P <br /> ry ❑Villa a Q�bwnshi of <br /> III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑ New System IX 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 /> Von <br /> of POWTS System: (Check all that apply) <br /> on-Pressuri ed In-Ground ❑ 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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) I System Elevation <br /> 7-:9-0 7 16 7;2- <br /> VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New I Existing <br /> Tanks Tanks <br /> Septic or Holding Tank 80 b 000 6 o o o2 td c. /} tz <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumbers Name( rin 0 Plumber's Signa arc MP/MPRS Number Business Phone Number <br /> 4tle. IfoF, 6r�— zz. 76 <br /> Plumber's Address(Street ,City,State,Zip Code) <br /> Qox spy Si� ¢ ••� AV 5-Y87 � <br /> VIII County/Department Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issui eor Signa (No Stamps) <br /> Surcharge Fee) 0 r/r r <br /> ❑ Owner Given Reason for Denial :/ <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complde plain(to Ne County only)for ehe ryetem on paper not leu than 9112 x 11 incha In size <br /> SBD-6398 (R. 01/03) <br />