Laserfiche WebLink
Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> VisclOnSin <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 Q <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to 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 I 1 inches in size. <br /> County State$ants 7]Srt Number Check i vision to pre ious application State Plan I.D.Number <br /> HJ`Al a <br /> I.Application Information-Please Print all Information Location: <br /> Property.Owner Name Property Location <br /> C-�1 A'r&5 1-34 1�P 1/4 1/4,S n TV6 ,N,R/6E(or) <br /> Property Owner's Mailing Add Lot Number Block Number <br /> 86 S c& 1) 1 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> a6yr � syd��o ( 4(6 6 LAP�9,u�P,gJo��o <br /> Il.Typ of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑Public/Commercial(describe use):_ 42own of <br /> ❑ State-Owned B rr I r U <br /> Nearest Road <br /> Parcel Tax Number(s) <br /> III.Type of Permit: (Check only one box on he A. Check box on line B if applicable) <br /> A) 1. ew 2. ❑Replacement 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 /> IVr Type of POWT System:(Check all that apply) <br /> X-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(Galslday/sq.ft.) (Min./inch) Elevation <br /> ys� 6 y3 <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 /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(pjint) Plumber's Signatur (no stamps): j!PIMPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 72 <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin ignatur tamps) <br /> RApproved 13Owner Given Initial Adverse Surcharge Fee) ,q <br /> Determination 2� 'I N1avc�l'a�f <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R 07/00) <br />