Laserfiche WebLink
Safety and Buildings Division County h-� <br /> 201 W.Washington Ave.,P.O.Box 7162 i YI <br /> Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co. <br /> Asconsin ) <br /> Department of Commerce (608)266-3151 4/ Q <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis,Adm.Code,personal information you provide 132 332 _ <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' C� l/ k;,J / /i fJ� <br /> Pro rt Owner's Name Parcel p T Lot d / C.-/� Block a <br /> Som , ory-ai�I-oil F60 <br /> Pr6pwy O is Mailing Address t Property Location <br /> �-7Co7 ter►- Sri jed c_ <br /> City,State(( Zip Code Phone Number 'K,St�'� Section <br /> �l s�` I / rcle <br /> 11.Type of Building(check all that apply) Tf0 N; IY�E <br /> �:l or 2 Family Dwelling—Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial—Describe Use <br /> ❑State Owned—Describe Use gCity_0Village'9Township of ll <br /> t <br /> III.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A. ❑New System ys �Replacement System ❑Treatment/Holding Tank Replacement Only '❑Other Modification to Existing System <br /> B. ❑ Perrrul Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to News List Previous Permit Number and Date Issued <br /> Before Expiration Plumbers Owncr <br /> IV.Type of POWTS System: Check all that apply) <br /> ❑ Non—Pressurized In-Ground RMound>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 Send Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leachin Chamber ❑Dri Line ❑Gravel-less Pi el" ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdso Dispersal Arca Required(st) Dispersal Asa Proposed(so System Elevation <br /> I/'�_D IY S-0 Y S� 1 160. 4, <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber plastic" <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> eptic o oldNew Existing / <br /> TWrs Tame <br /> Sing Tank s/ /0610 <br /> aU r-1 p <br /> Aerobic Treatment Unit <br /> sing Cha r .)c <br /> XI <br /> VII.Responsibility Statement-I,the u designed,■ me responsibility for installation of the POWTS shown on the attached plana. <br /> PI b is Name( 'nt PI mber's Signet MP/MPRS Number Business Phone Number <br /> X7, 6- ✓ 22522 7/1 �(olo-�(PL-11 <br /> Plumber's Address(Street,City,State,Zip Code), <br /> 7(f Yr 6)v jej -h (,Delo Ccs; <br /> VIII.County/Department Use On] <br /> Approved ❑Disapproved Sanitary Permit Fee includes Groundwater Date Issued lasui Age Signature tamps) <br /> Surcharge Fee) /0 <br /> ❑Owner Given Reason for Denial <br /> DL Conditions of Approval/Reasons for Disapproval <br /> Attach complete pion,(to the County only)for the system 04 paper Not Its.than 81/2 x I l Inches in size <br /> SBD-6398 (R. 01/03) <br />