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 /> 1 isconsin 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 only)for the system,on pap not less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Permit Number ❑C e if re ision to previo application State Plan I.D.NumberQ0I`11� <br /> 00,3\ 4a <br /> I.Application Information-Please Print all Information Location: <br /> Property 07er amee/ Property Location <br /> 7 Z47U` (Gtr 41 AjP40'014% 1/4 1/4,S e/T ;§-,N,R/*(or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> c)ye r -43n err ve <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> /q;d/� 4177n/. <br /> II.Type of B ilding: (check one) 3 ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ Town of <br /> ❑State-Owned T cx Lo & 't <br /> Nearest Road 66 <br /> 0 Z <br /> Parcel Tax Number(s) <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) l I <br /> A) 1. M New 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) <br /> ElPermit Number Date Issued <br /> A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> Cl Non-pressurized In-ground ATMound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.DispersaVY'reatment 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) Elevation <br /> -//SO '� 'o (/So oa to z•Xn /dY27 <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> /GrIv &.Y ese f In ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of Lp2POWTS shown on the attached plans. <br /> PI is Name(pri Plumber 'gnatu n ps): MP/MPRS No. Business Phone Number <br /> oOPr <br /> Plumber's Address(StreetCity,State,Zip Corley If <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent Signature(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) a <br /> Determination I aa).' Cc) �� I2L Lffla;, <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />