Laserfiche WebLink
A�am'100 <br /> Sanitary Permit Application IVSafety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> `�SVonS'II See reverse side for instructions for completing this application Madison,WPO Box 7302 <br /> 7302 <br /> Personal information you provide may be used for secondary purposes <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 system,on paper n t less than8-1/2 x 11 inches in size. <br /> County State S itary ermit Number ❑ eck if rev' ion to previous a lication State Plan I.D.Number <br /> g a� a <br /> I.Application Information-Please Print all Information Location: <br /> Prope Owner Name t Property Location JAC y <br /> El4S e14,S 3 T-YA,R r$(or <br /> Property Owner's Mailing Address Ip� Lot Number Block Number <br /> -:24141d <br /> City,StateZip Code Phone Number Subdivision Name or CSM Number <br /> 5411 44IC-1 ":r1,5-q5V1 71 <br /> II.Type of Building: (check one) ❑city <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: 02 ❑Village <br /> ❑Public/Commercial(describe use):_ =Town of <br /> ❑State-Owned 4-p-W e <br /> Nearest Road PO <br /> Parcel Tax Num c5g ;7/03r 036 J <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) <br /> El Permit Number Date Issued <br /> A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground 8fmound ❑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 Elevation7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 30 la'©, <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> 73-0 ,1 <br /> �S'b ❑ ❑ ❑ ❑ <br /> Sac) S—dd ❑ ❑ ❑ ❑ <br /> �r� <br /> I.Resp risibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(pri t) ` Plumber's Signature no stamps): MP/MPRS No. Business Phone Number <br /> fj�/r�/irl � �z�L 9 � <br /> Plumber's Address(Street,City,State,Zip Code) z� <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee Vpcludes Groundwater Date Issued Issw Agent Signature(No stamps) <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee) as�. Q� /�/ as <br /> Determination J 10 U L <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R 07/00) <br />