Laserfiche WebLink
oatoryInassuuttmgsutvtaron I:ounry <br /> MR W 201 W.Washington Ave.,P.O.Box 7162 <br /> iS�nS Qcc rn <br /> Madison,WI 53707-7162 Site Address <br /> Department of commerce 71S"t t!rnColn 5� <br /> Sanitary Permit ApplicationI Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide //\ <br /> maybe used for sec ses Privac Law,s15 11(m) 11 Check if Revision 4-3 VVc) -,_c_- <br /> I. <br /> Application Information-Please Print All Inf0rM2d0n3-7State Plan I.D. Number Nil <br /> Property Owner's Name / ' Parcel Number 4 1 /� I /� <br /> bon G Wckuf 00\0 ! J+J O11f/V <br /> Property Owner's Mailing Address Property Location <br /> franklrn <br /> SW tk WE tit:S 3Q, T ttO N.R 16 <br /> City,Stare Zip Code Phone Number I Lot Number Block Number <br /> Subdivision dame CSM Number <br /> M4h>omedt l' IV. SS/l�S" 6S�- y�G' 36�s' <br /> ✓eF�rt,es �sta�es <br /> R.Type of Building(check all that apply) ❑City <br /> 1 or 2 Family Dwelling-Number of Bedrooms ❑Village <br /> ❑Public/Commercial-Describe Use Rrownship 0A L-14. j <br /> ❑State Owned Nearest Road <br /> Grr+coln S� <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. i J9 New 2 ❑ Replacement System 1 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> ste I Tank Only Existinit System <br /> B, ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> W.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Weiland <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 Ram(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> ISQ O.16 116 . 7 -- 93, i 97 <br /> VI. Tank Info Capacity in Total Number Manufacturer I Prefab Site SteelI Fiber Plastic <br /> Gallons Gallons of Tanks <br /> Concrete Constructed , Glass <br /> New Existing <br /> Tanks Tanks 1, <br /> Septic or Holding Tank /,goo _ i �AJG .6. yerff/,�SGQ <br /> Dosing Chamber <br /> i <br /> VII, Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) ?!umber's Signature NIP/MPRS Number Business Phone Numcer <br /> lumbers Address(Street,Cary,State, Zip Code) <br /> 2-7-7 &o 14w 315 £B I , X4_8 3 <br /> \VjII. County/Department Use 0filv <br /> Approved El Disapproved Sanitary Permit Fee(includes Groundwater Date Issued ! issuing. _n gna. ,.'o Sramcs:- <br /> Surcharge Fee) �5-(A <br /> ❑ Owner Given Initial Adverse � aPv��� -02} <br /> Determination l/lJ <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> � �4y <br /> eU 1 y <br /> Attach complete pians(to the County only)for the system on paper not less than 81,13 s Ii inches in size 1�p LV <br /> C011 <br /> SBD-6398 (R. 05101) <br />