Laserfiche WebLink
Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O. Box 7162 <br /> lVisconsin Madison,WI 53707-7162 Site Address <br /> De artment of Commerce <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21•Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15. 1 m ❑ C k t Revision .� <br /> I. Application Information-Please Print All Information State Plan I.D. Number <br /> Property Owner's Name Parcel Number <br /> 90 Dao- ?3;,?— OD- 701 <br /> Pr pe�rty Owner's Mailing Mailing Address ��- �J Property Location �Q ,{�, <br /> bI aAl j �^ "J(^�l 0 �k 'A:S ; tT`[P N,R <br /> City,State Zip Code Phone Number Lot Nether Block Number <br /> 5 <br /> PIN . Subdivision Name CSM Number <br /> V is <br /> II.Type of Building(check all that apply) <br /> 3 ❑City <br /> 1 or 2 Family Dwelling-Number of Bedrooms ❑Village �/�, �„ <br /> ❑Public/Commercial-Describe Use ownship 0049LA b <br /> ❑State Owned Nearest Road <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> f <br /> New 2 11 Replacement System 3 E) Replacement of 6 C1 Addition m For County use <br /> stem I Tank Only Existing Sys <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 -Non-Pressurized In-Ground 21❑ Mound 47❑ Sand Filter 50 El <br /> 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./Days/Sq.Ft.) (Min./Inch) O Elevation <br /> X4. 3 S <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank <br /> Dosing Clamber W <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 MPRviPRS Number Business Phone Number <br /> �fFRo2� nls 22SS S 715- 46- 41S7 <br /> lumber's Address(Street,City.State,Zip Code) <br /> 27-7 &o 4w-f 315 ugs-qm �4$ 3 <br /> VIII. CountyDepartment Use Ofily <br /> pproved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Age SignatureN ramps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse <br /> Determination <br /> IX. Conditions of ApprovallReasons for Disapproval <br /> Attach complete plana(to the County only)for the system on paper not less than 81/2 x 11 Inches In she <br /> SBD-6398 (R. 05/01) <br />