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 /> Visconsin 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.) r <br /> Attach complete plans(to the county copy only)f9pthe system,on pape not less than 8-1/2 x 11 inches in size. lJ <br /> County State S i Permit Number C eck if vision to revio application State Plan L D.Number <br /> u/'N e <br /> I.Application Information-Please Print all Inforination Location: <br /> Property Owner Name Property Location <br /> e-A-) 5 r 1/4 1/4,S T y/N, E(or)Q <br /> Property Owner's Mailing Address Lot Number Block Number <br /> a v,*Xe_ w,4 UNi 7� y <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 04f Alit'- A), j cis/ ) _?f/9 <br /> II.Type of Building: (check one) ❑city <br /> 12r— 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ XTown of <br /> C <br /> ❑State-Owned Slt//S s <br /> Nearest RcLad <br /> Parcel Ux Number(s <br /> 0 <br /> I11.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. eplacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> •C,YSIon-pressurized In-ground 11 Mound ❑Sand Filter ❑Constructed Wetland <br /> 0 Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment 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(Gals./day/sq.ft.) (Min./inch) Elevation <br /> c3d ° <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 /> t Tanks I Tanks <br /> 7So 7S6 p` ❑ ❑ ❑ ❑ <br /> f`_ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber s Name(prin�tj Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 43 O X S ./Y S //`G.. <br /> IX.County/Department Use Only <br /> ❑Disapproved I Sanitary Pemu (Includes Gro ndwater Date IZ5/DZ,l <br /> Issuing A e ign s ps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fe /�� <br /> Determination p�w ' -/ <br /> X.Conditions of Approval/Reasons for Disapproval: i77:111A 'a <br /> -JUL ;1 2002 <br /> SBD-6398(R.07/00) ZONING <br />