Laserfiche WebLink
Safety and Buildings Division County <br /> ` 201 W. Washington Ave., P.O. Box 7162 <br /> 1seonsin Madison, WI 53707-7162 Sanitary�P�es it Number <br /> (to be filled in by Co) <br /> � <br /> Department of Commerce (608)266-3151 'T��O 35co <br /> Sanitary Permit Application Slate Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm. Code,personal information you provide _Z1__ <br /> may be used for secondary purposes Privacy Law, 05.04(1)(m) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel N Lot N /2 Block N <br /> L o LA- ^ o v ` 14 tiJ <br /> Property Owner's Ma iling A ress —6 0 �2 -2 66 <br /> Property Location <br /> City,StateZip Code Phone Number '' 'ti,Section 51 <br /> / <br /> 11.Type or Bui 'ng(check all that apply) T N; RLL <br /> ?� Subdivision Name.or 2 Family Dwelling-Number of Bedrooms Q914-Number <br /> ❑Public/Commercial-Describe Use ~—" c — Ae,4 c- �/'e j <br /> ❑State Owned-Describe Use ❑City_❑vdbige)!�l-owruhip of <br /> 111. Type of Permit: (Check only one box on line A. Complete line B if applicable) S <br /> A' ❑ New System )"teplacement System ElTreatment/Holding Tank Replacement Only El Other Modification to Existing System <br /> B. EJ Permit Renewal - /❑ Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV. Type of POWTS System: (Check all that apply) <br /> VtNon-Pressurized In-Ground ❑ Mound > 24 in. of suitable soil ❑ Mound G 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 A ea ired(so Dispersal Area Proposed(so System Elevation <br /> VI, Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or YoldRlg'hnk Q0� �l](J �� <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached platys. <br /> Plumber's Name(Prin t) Plumber's Signa rule MP/MPRs Number Business Phone Number <br /> en/ <br /> Plumber's Address(Street , City,State,Zip Code) /', <br /> VII .County/Department Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued lssuin t Signam Stamps) <br /> C <br /> ❑ Surcharge Fee) WOwner Given Reason for Denial � �50 / 271 <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Aueeh complete plana on the County only)for the system on paper not leas than 8112 x 11 luchr In size <br /> SBD-6398 (R. 01/03) <br />