Laserfiche WebLink
Safety and Buildings Division Cou <br /> M M 201 W. Washington Ave.,P.O. Box 7162 - V <br /> `�Sco.1S�1■ Madison,WI 53707-7162 Site Address <br /> Department of Commerce I IQ Q <br /> Sanitary Permit Application San ary Pe mit Num r <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> ma be used for seen purposes PrivacyLaw,s15. 1Hm 11 Check if Re inion <br /> I. Application Information-Please Print All Information State Platt I.D.Number <br /> Property Owner's Name Parcel Number ( , <br /> Property Owner's Mailing Address Property Location <br /> j S W <br /> � �r`�'e-1� �e-'e-- Sf Si;S - LIT ON.R I <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> Mevn� c �• II$ <br /> S "C\InS 4 1_ c^2 q3S— SOI Subdivision Nam CSM Number <br /> II.Type of Building(check all that apply) tE J <br /> []city <br /> 04 or 2 Family Dwelling-Number of Bedrooms <br /> 3 <br /> ❑ra,/V�illage <br /> ySl <br /> ❑Public/Conuncrcial-Describe Use owmhip 's CJD a\ <br /> ❑State Owned Nearest Road <br /> c <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal nue). Complete line B f applicable) <br /> A. I New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> system I Tank Only Existing System <br /> B- ❑ Check if Sanitary Permit Previously Issued Permit Number Da c Issued <br /> IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 on-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50 C1Constructc Welland <br /> 2 Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ElDrip Line <br /> 45 At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 3o❑Other <br /> V. Din ersal/Treatmeat Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elev34on Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) � &-'1 Elevation <br /> 9 F <br /> VI. Tank Info Capacityin Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Galioas of Tanks Concrete Col unscmd Glass <br /> New Existing <br /> Tanks TaNcs <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> VD. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) PI ber's Sign toe MP/MPRS Number usiness Phone Number <br /> Kwk i4 gay o 71$ �3S-aBF � <br /> Plumber's Address(Street, ,Sum,Zip Code) <br /> 5 S O `Z `Dae I_ t, tee S 6ar-er %t S-q <br /> Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing eat Signatur o Stamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse '9 50� n/�q 11 <br /> Detemtination ��CCJJ <br /> IX. Conditions of ApprovalfReasons for Disapproval <br /> V <br /> JUL 2 3 2007 <br /> Attach complete plans(to the County only)for the system"paper not less than 81/2 a Illnstep) ¢5E� COUNTY <br /> SBD-6398 (R. 05/01) �u �VZONING <br />