Laserfiche WebLink
37o t 9 7,5,00 <br /> Sanitary Permit Application Safety&Buildings D 'o <br /> ' In accord with Comm 83.21,Wis.Adm. Code 201 W.Washingto <br /> See reverse side for instructions for completing this application PO Box <br /> ` isconsih personal information you provide may be used for secondary purposes Madison,WI 5370 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county n t <br /> state o <br /> Attach complete plans to the county copy only)foL the system,on paper not less than 8-1/2 x I 1 inches in size. <br /> County State Sanitary Pe it Numbereck i revision to previ application State Plan I.D.Number <br /> I.AppTication Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> DEA�J /4,S ST N, o <br /> Property Ownees Mailing Address of Number Block Number <br /> . 0. PSC, 4z <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 1nlC�SiZ W1 �� gS� 4373 <br /> Type <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑village <br /> ❑ Public/Commercial(describe use): Town of <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. X`New System 2. ❑Replacement 3. ❑ Replacement of 4. ❑Addition to Parcel Tax Numbs) <br /> S stem Tank OnI Existin S stem <br /> B) Permit Number ate Issued <br /> ❑A SanitaryPermit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑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 /> I.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.R.) (Min./inch) Elevation <br /> 4sD 45D X575 7 ,0 '0q9- 8 jn1 . 6 <br /> VI.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 e <br /> C 10019 [c�Op �` ❑ ❑ ❑ ❑ ❑ <br /> V11.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no stamps): MP/MPRS No. �+ Business Phone Number <br /> G�vracr/ i✓ �S�J S - �5� <br /> umbers Address(Street,City State,Zip Co e) <br /> 2-7760 35' W156 E'K W1. 54893 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fe (Includes Groundwater Date sued Issuing nt Si 1 o tamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) �O �� O <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />