Laserfiche WebLink
Safety and Buildings Division County <br /> ` 201 W.Washington Ave.,P.O.Box 7162 ,80.v H el'?, <br /> Madison,W1 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> isconsin <br /> Department of Commerce (608)266-3151 '" 35-7 <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.2 1,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,a]5.04(I)(m) Project Address(if different than mailing address) <br /> at <br /> I. Application Information-Please Print All Information 8010�/ S tI0lf aJ�nX/ZU' W <br /> Property Owner's Name Parcel# Lot# Block# <br /> GIA/f Ch;/oPdes bolo yj,L3 094000 <br /> Property Owner's Mailing Address Property Location 60V I—,60T / <br /> AM A/able 16,6 d! 10 <br /> City,State Zip Code Phone Number —YA —�• Section 013 <br /> &ryvltl, "& A"V SS9a3 743xert 4/97Jr (circleoV) <br /> T y0 <br /> II.Type of Building(check all that apply) N; R /fr E or&/ <br /> 501or2 Family Dwelling-Number ofBedrooms d` <br /> Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑Village®Township of 0#rt/d r� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A_ ❑New$ stem <br /> y ,a Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. 11 Permit Renewal El Permit Revision El Change of El Permit Transferor New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> J R Non-Pressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 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 Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dis ersaVrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(sf) System Elevation <br /> :3 1 . .5— 1 6 00 600 9S & <br /> VI.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 8�B Qat fin c.� k <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-f,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 /> Ne k;a! /oys.. ,td's�r/ �.r-saG-y%r•� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> jA7-760 ,/,i 3s wBbr><<✓ e✓r- .Syff93 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin g Signature o Stamps) <br /> Surcharge Fee) 250f 1212 7 D r <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Athch complete plana(to the County only)for the system on paper not lora flus.alb.11 Riches in Stu <br /> SBD-6398 (R. 01/03) <br />