Laserfiche WebLink
Safety and Buildings DivisionCou I? <br /> 201 W. Washington Ave., P.O. Box 7162 U y/`iU r✓ <br /> Misconsin Madison, WI 53707 -7162 Site ddress <br /> De artment of Commerce , I <br /> Sanitary Permit Application San tary Permit Num r d <br /> in accord with Comm 83.21,Wis.Adm. Code,personal information you provide e <br /> may be used for second purposes Privac Law,sl 1 m ❑ Check if Revision4795 3 <br /> I. Application Information-Please Print All Information State Plan I.D. Number Q� <br /> T" <br /> Property Owner's Name /f�J / Parcel Number <br /> LO rCer✓ r E/J / 0_2 <br /> //U <br /> Property Owner's Mailing Address Property Location PC- G� L. <br /> 93 3 ^/ R 56:5 OTY6 N.RIC/ E <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> V'/- —Subdivision Name CSM Number <br /> e .Jv r Ui irr n il SSS 3 <br /> ,/.'Type of Building(check all that apply) ❑City <br /> IO.I or 2 Family Dwelling-Number of Bedrooms ❑Village <br /> (❑P <br /> �ublic/Commercial-Describe Use �— ownship .,SC _ <br /> ❑State Owned earest Road T <br /> III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if app cable) <br /> A For County use <br /> 1 ❑ New 2�Beplacement System 3 ❑ Replacement of 6 ❑ Addition to <br /> S stem Tank Only Existin S stem <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 91lon-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 Rax System Elevation Final Grade <br /> Required g Proposed Rax(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> VI.Tank Info <br /> Cap try in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallo Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks ranks <br /> Septic or yolding'79nk 7-S <br /> Dosing Chamber 5� S'Q� <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. _ <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> e,j#./e e, Fae%h — Z Z <br /> Plumber's s Address(Street,City,State,Zip Code) <br /> Dt, <br /> V3IL Cotmt /De artment Use Onl <br /> Sanitary PermitFee(includes Groundwater Date Issued Issuin Agent Signature(No Stamps) <br /> Approved 1-1Disapproved Surchar a Fee) <br /> ) , ate.c y' D &a �Y ,n <br /> ❑ Owner Given Initial Adverse <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plain(to the Couaty only)far the ydem on paper not len than 81/2 x 11 inches In size <br /> SBD-6398 (R. 05101) <br />