Laserfiche WebLink
jDepar�:tmFent <br /> Safety and &l A%e., Dnulox Courcy <br /> 201 R'. %4whington;ice..P.O. Bux 716' L3 urn etf'onsin Nladison, )i2U7 -7162 Sanitarr'y'PelImtn Number(to be illeJ in by of Commerce (60b)266-3 151 ZT--h5 729 ;-d ag <br /> Sanitary Permit Application State Plan ID Number (� \ <br /> In accord with Comm 83_21,Wis.Adm.Code,personal information you pro,idc 982 Ig ( J�f_J <br /> may be used for secondary purposes Privacy Law,sl i 0.11 I)(m) Project Address(if dif ferem than inadmg address) <br /> 1. Application Information—Please Print All Information <br /> Seven4A P4. <br /> Property Owner's Name Parcel a Lot X Block i <br /> 40enn Y 60L, <br /> Property Owner's Mailing Address / <br /> Property Location LoT ( Cbt1✓fIp Pr 1(/ <br /> p' <br /> SO 745 S fafe l+na Pj <br /> N Al�� section <br /> City.State Zip Code Phone Number <br /> S6hds�one mN sSo 7t ado-d9,L-3/bS" (circle one) <br /> 11.Type of Building(check all that apph) <br /> T 4t N; R J6 Eo�Lfa%/ <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms Subdivision Name /� CSM Number <br /> k.Public'Commercial-Describe Use o FF r e G 47";1141,145 U. l b R /&/— I&A <br /> 11 State Owned-Describe Use ❑City_❑Village®Townshipof SW/SS W <br /> III.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A. <br /> RtNew System ❑ Replacement System ❑ Treatment.Holding Tank Replacemem Only ❑ Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> rIV.TNpe of PO«'TS System: Check all that apply) <br /> yx Non-Pressurized In-Ground ❑ Mound>224 in.of suitable sod ❑ Mound<Ia in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filler ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil ApplicationRotel gpJst) Dispersal Area Required(st) Dispersal Area Proposed(sD System Elevation <br /> 7s r 7 i/a 43d 93. v <br /> Ill.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank goo $,QO , $k Aw <br /> Aerobic Treatment Unit O ✓C <br /> Dosing Chamber <br /> VI 1. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POW TS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signatur MP MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Cole) <br /> o47760 Y.,y WeAjr ,r wl" X893 <br /> kXC <br /> untv/De artment Use Onlvved ❑ Disapproved Sanitary Permn Fee includes Groundwater Date Issued Issu. Agent Signature(No Stamps) <br /> Surcharge Fee) QS� � �❑ Owner Given Reason for Denial ���(((---PPP O� 1 Awn I / 1�?n <br /> ditions of Approval/Reasons for Disapproval <br /> APR 2 _ 21 <br /> Attach complete plans(to the County onl))for the system on paper not less than NIR a it inches <br /> ZONING <br /> SBD-6398 (R. 01/03) <br />