Laserfiche WebLink
Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> `4sconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <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 1 I inches in size. <br /> County State Sanitar}�P rm*,Nu r ❑Check_ revision to application State Plan I.D.Number <br /> (LTTl5J ZlalL =F <br /> I.Application Information-Please Print all Information Location: DIA <br /> Prope erName Property Location <br /> qh y et 1/4 1/4,S / T a <br /> YO,N,l <br /> Pro Owne s Mailing Ad ss Lot Number Block Number <br /> . ,66.E &I y <fe/ 6 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Z C / S60,62r ( � > <br /> II.Type of Building: (check one) ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: 2 ❑Village <br /> O+fown of <br /> ❑Public/Commercial(describe use):_ L <br /> ❑ State-Owned //fc lC son <br /> Nearest Road <br /> / ,J <br /> Parcel Tax Number(s),,/2 PC-P f off'64 30 <br /> 1II.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. Iff New 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permi[Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> 19 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(Gals./day/sq.ft.) (Min./inch) Elevation <br /> S66 `/z 8 �/3�. y� . '7 y0 <br /> 18'•�4 <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 /> ese— <br /> ® ❑ 11 ❑o / W.` f <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu ber's Name 7ri Plumber' �gna stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) _ <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing A t gnature ps) <br /> Y Approved ❑Owner Given Initial Adverse Surcharge Fee) �� <br /> Determination <br /> 30 <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> MaY C 5 <br /> SBD-6398(R.07/00) <br />