Laserfiche WebLink
sV <br /> Sanitary Permit Application Safety&Buildings cion <br /> �� In accord with Comm 83-2 1,Wis.Adm. Code 201 W. Washingt e, <br /> 'ViseonsinSee reverse side for instructions for completing this application POB 2 <br /> Department of commerce Personal information You provide may be used for secondary purposes Madison,WI 537002 <br /> [Privacy Law,s. 15.04(l)(m)] (Submit completed fortal to court of <br /> Attach co, fete lans to the coun co onl )for the stem,on a er not l than 8-1/2 x I 1 inches in size. state o <br /> County State Sanitary P it m <br /> Cha rev to t�revious appy tion State Plan L D.Number <br /> I.A ication Information- Please Print 1 nformation , <br /> Property Owner Name Location: <br /> 1 L RrrLf+C0(* Property Location ��jj�� <br /> Property Owner's Mailing Address l/4 1/4,Sl�.Jr A10.N,ASE or W <br /> 2 /!'^� '.E h n_LL O n_ Lo berg Block Number <br /> City,State IVC t V[)Zip -tc:o/ a <br /> Phone Number ' M Number <br /> AiJn�`a Wk X4830 ( lS )251 - 2 vision Name or CS0V69 xa•Na Anv to v- <br /> II.Type of Building: (check one) <br /> ,X 1 or 2 Family Dwelling-No.of Bedrooms: ❑City <br /> ❑ Public/Commercial(describe use): ❑Village <br /> f <br /> ❑ State-Owned Town o <br /> III. Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> LB) <br /> 1. X New System 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Addition to Parcel Tax 6''6021ANO -rR <br /> S stem Tank Onl ExistingSystem I Permit Number <br /> ❑A Sanitary Permit was previously issued Date Issued <br /> IV.Type of POWT System: (Check all that apply) <br /> D(Non-pressurized In-ground ❑ Mound <br /> ❑Pressurized In-ground ❑Sand Filter ❑Constructed Wetland <br /> ❑At-grade ❑ Holding Tank ❑Single Pass ❑Drip Line <br /> El Aerobic Treatment Unit 11 Recirculating 11 Other: <br /> 1.Design <br /> is ersal/Treatment Area Information: <br /> 1. esign Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6. <br /> Re aired Proposed Rate(Gals./day/sq.ft.) (Min./inch) System Elevation 7.Final Grade <br /> 3�� �j0 0 Elevation <br /> °� 9j &A o <br /> VI.Tank Capacity in Total of <br /> Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks <br /> New Existing Con- Con- <br /> glass <br /> Tanks Tanks Crete structed <br /> v�13r1� 1000 -- (oob 1 �IORWESI.o ❑ ❑ ❑ ❑ <br /> VII. 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):P ) MP/MPRs No. Business Phone Number <br /> Y'l ��Adeo �, I ?,zSBsi <br /> umber's Address(Street,City State,Zip Code) S07 <br /> 2--77(003S WEsSTF.R WI. 54$93 <br /> VIII. County/Department Use Only <br /> ❑Disapproved Sanitary Permi a(Includes Groundwater Date Issu <br /> -41CApproved ❑Owner Given Initial Adverse Surcharge F Issuing Ag gnamr s) <br /> Determination S 3 d <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />