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 Submit completed form to <br /> [Privacy Law,s. 15.04(1)(m)] ( P county if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> County State Sanitary pe���Iumber ❑Check rev on to previous application State Plan 1.D.Number <br /> v� e Jy6� <br /> I.Application Information-Please Print all Information Location: <br /> PropertyOwner yNaome Property Location <br /> wez Ile f R"L e 61E� 1/4—'U-- 1/4,SJF2 TJr,N,Rl5(or)® <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 4'7s <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 3y/7 ( �iis ) zy6. 6ssy <br /> I1.Type of Building: (check one) ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms:-17 ❑Village <br /> ❑Public/Commercial(describe use):_ PA Town of <br /> ❑ State-Owned <-/q 14--ol/Le f1 e0 <br /> Nearest Road�/t1 <br /> C.ovn ��t?e <br /> Parcel Tax Number(s)O�.l�3z <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) 77_ <br /> A) 1. IN New 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Numb <br /> 11A Sanitary Permit was previously issued er Date Issued <br /> IV.Type of POWT System: (Check all that apply) <br /> 29 Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑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 /> G/sZS (vy2 .1�6 Ce 53 . I / < "( 7ID, & 571% 7 <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 /> /DDo I LJrrl°Ser ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plum ''s Name(print) Plumb Signa a(n tam s): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) _ <br /> IX.County/Department Use only <br /> �zO Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing A t na7Z4P4A,,'— <br /> AW <br /> s) <br /> [>3 Approved ❑Owner Given Initial Adverse Surcharge Fee) ��/, / �� �� <br /> Determination V 1 <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> '1 <br /> UNTy <br /> SBD-6398(R.07/00) 4QN/NG <br />