Laserfiche WebLink
Safety and Buildings Division County <br /> Vi 201 W. Washington Ave., P.O. Box 7162sconsin Madison, WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 LD Jf 2 2 3 <br /> Sanitary Permit Application State Plan I.D. Number <br /> In accord with Comm 83.21,Wis.Adm. Code,personal information you provide <br /> may be used for secondary purposes Privacy Law, sl5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information <br /> 27823 a �& T <br /> Property Owner's Name / `1 r� Parcel# Lot# Block# <br /> i C �i 4L � /<O 'J /Pt J�'/ .2✓�/J it/) _,y <br /> Property Owner's Ma iling Address Property Location <br /> .26 3V S C e /,-a `c% 6-!d 9S�'-F` P"' - Iv 85--3 <br /> City,State Zip Code Phone Number/ / 5 'A, Nt'.t,Section <br /> c cx 6 <br /> 4S47a t..,> f V�� w j�6 Y6 d 4o (circle one) <br /> II. Type of Building(check all that apply) T rV N: R_L(0_L*or W <br /> ,f$1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use []City_L]Village Xfowmhip of CAyid kid, <br /> III. Type f Permit: (Check on one box on fine A. Complete line B if applicable) <br /> A. New System Replacement System ❑ Treatment/Holding Tank Replacement Only 11Other Modification m Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV,Type of POWTS System: (Check all that apply) <br /> on-Pressurized In-Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter <br /> ❑ Constructed Weiland ❑ 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. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> -7 ,101_�__ OD OO 3� <br /> VI. Tank Info Capacity in Total Number Manufacturer Prefab Site I stfel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank 6 75ZC <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Prin t) Plumber's Signa lure MP/MPRS Number Business Phone Number <br /> �e� �l�j>'-6; 7/s — 3`/9— s Z 6f� <br /> Plumber's Address(Street , City,State,Zip Code) T <br /> VIII. County/Department Use Old <br /> 17J Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing A S' namr mps) <br /> Surcharge Fee) <br /> El <br /> J0 ' <br /> ❑ �qt <br /> Owner Given Reason for Denial rti !N <br /> IX. Conditions of Approval/Reasons is ytvval <br /> (2EiJtSIO�U : T(tAWSF0t of XUM 664 SSU"° /3 JUNE o(o <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />