Laserfiche WebLink
Safety and Buildings Division County <br /> N*ftconsin 201 W. Washington Ave., P.O. Box 7162 <br /> INIR <br /> Madison,WI 53707-7162 Site Adcliess <br /> De artment Of Commerce <br /> Sanitary Permit Application SatttWY Permit Number � <br /> I. <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide eta �y 7 / <br /> May be used for secondaryPurposes Priva Law s15. 1 m) El Check if Revision I 0 <br /> Application Information-Please Print All Information <br /> Property Owner's Name <br /> a ag State Plan I.D. Number <br /> Parcel Nryumber <br /> Property 6ae 's Mailing ddress 012 01 101 <br /> Property Location <br /> 7�� W <br /> City,State Zip CodeFPhonember �4 5 'bSIj T A40 N,RLot Number C�. <br /> lerSubdivision Name CSM Number <br /> ChaoN W: 5y004' ls 9 7 St".►N V; .Q'/S 1iT D�G�L S <br /> II,Type of Building(check all that apply) <br /> �1 or 2 Family Dwelling-Number of Bedrooms 2 ❑City <br /> ❑Public/Commercial-Describe Use ❑vaiage <br /> ❑State Owned XTownshtp 94Xk5QN <br /> IN Road <br /> III.Type <br /> of Permit: (Check only one box on line A (numbering scheme for internal use). Completeline B if applicable) <br /> A. <br /> 1 .p New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to Y <br /> For Count use <br /> System Tank Ord Exis, 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 Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter <br /> 50❑ Constructed Worland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass <br /> tng 510Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49 11 Recirculating 30 11 Other <br /> V.D' enal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil A lication <br /> Required Pp Percolation Rate System Elevation Final Grade <br /> 3d� w Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> �z� 3z <br /> . 7 - g y,� 9V-5- <br /> VI.Tank Info Capacity in Total Number Manufacturer <br /> Gallons Gallons of Tanks Prefab Site Steel Fiber Plastic <br /> New Exisfine Concrete Constructed Glass <br /> Tanks ranks <br /> Septic or Hadi,tg rank 6c <br /> Das ChChamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Priv[) Plumber's Signature MP/MPRS Nmberu <br /> Business Phone Number i <br /> Plumber'sAddress(street,City,State,Zip Code) 2ZS$S 715- $66— 4157 <br /> 27 7 &Q {-{w �S X48 3 <br /> 1. Count /De artment Use 061 <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin gent Sig re(No Stamps) <br /> Surcharge Fee) <br /> 11 Owner Given Initial Adverse <br /> Determination <br /> 1X. Conditions of � pproval <br /> AttarL complKe plain(to the county OtY)for the system on paper not lean than sOURNEl/2 x 11 lachn fo a[ze <br /> SBD-6398 (R. 05/O1)ZONINGUNTM <br />