Laserfiche WebLink
'Viseonsin 201 W. Washington Ave.,P.O.Boz 7162 Gecrn <br /> Madison,WI 53707-7162 r Site Address <br /> Department of Commerce t < �f <br /> Sanitary Permit Application S"ituy Pe it° o i� <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary es Privacy Law. 15. 1)(m) ❑ Check if Revision <br /> I. Application Information-Please Print All Information Sure Plan I.D.Number <br /> Property Owner's Name Parcel Number <br /> (L'A txrni Gine /1/>°lwn od b - 9/00 , 0-3(ow T <br /> Property Owner's Mailing Address /1 h til Property Location <br /> P.O. Qex 3 7 3S3 Is/. U Old tlo1 4 $A Si:S 3Y T rf0 N.R I b 4' <br /> City,State Zip Code Phone Number " Lot Number Block Number <br /> ,1 <br /> Subdivision Name C $Number <br /> US a ti 6:A- { s <br /> Sud. ,I <br /> H.Type of Building(check all that apply) ❑City OF- L-ery a CG `Y 3 <br /> (� 1 or 2 Family Dwelling-Number of Bedrooms ❑Village I <br /> ❑Public/Commercial-Describe Use <br /> (�T'ownship Or}(✓(sitel <br /> ❑State Owned Nearest Road <br /> E. I)eui& Lk (fid, i <br /> M.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. 1 It New 2 ❑ btcemcm System 3 ❑ For County use <br /> Rep Replacement of 6 ❑ Addition m <br /> System Tank Onl S stem <br /> B• I ❑ Check if Sanitary Permit Previously Issued Permit Number Date issued I <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 Non-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Constructed Wetland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51❑Drip Line <br /> i45❑ At-Grade 46 C1 Aerobic Trearmen[Unit 49❑Recirculating 30❑Other , <br /> V.Dispersal/Treatment Area Information: <br /> Design Flaw(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rare(Gals./Days/SgXt.) (Min./Inch) Elevation <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site I Steel Fiber I Plastic j <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Exiatfr[g I � <br /> Tanks Tanks <br /> Septic or Holding Tank 410,0 Neral pj(�j ' . <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumbcr s Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> e-*Vi) /Ws Z2-SSS 15- 866- 41S7 <br /> Plumber's Address(Street,City.State,Zip Code) <br /> 2-7 7 (o O 14w 35 <br /> VUj<1Co;mty/De artment Use Ofily <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing a itamps) <br /> Surcharge Fee) <br /> C1 Owner Given Initial Adverse '1 rrr� 1,7 <br /> Determination <br /> DermDetermination �pon Q({�(� V0 / tK., 0,7 t gnarure <br /> vhm <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than al/2 x 11 inch"in siz <br /> SBD-6398 (R. OS/Ol) <br />