Laserfiche WebLink
38 og <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> VA'sconsirn See reverse side for instructions for completing this application PO Box 7302 <br /> Department of Commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> [Privacy Law,s. 15.04(lxm)] (Submit completed form to county if not <br /> Attach tom Iete lens to the coon co onl )for the s stem,on a er not less than 8-1/2 x 11 inches in size. state owned. <br /> County State SariPermit Number <br /> J heck if r vi on torevious application Stale Plan[.D.Numbdr <br /> I.ApplicationInformation-.Please Print all <br /> er nformation <br /> Property OwnName Location: <br /> DR UP SurOYr Property Location <br /> m� <br /> Property Owner's Mailing Address Stv l/4 NW 1/4,S1S" T 40 ,N R`6 E or <br /> �,/L <br /> Lot Number Block Number <br /> o� 7$O�l c,„rlhnsan d <br /> City,State Zip Code <br /> �,/ Phone Number Subdivision Name or CSM Number <br /> i'1!�6s><r✓'- w 5`�f t�7�' >�s' Yi <br /> II.Type of Building: (check one) <br /> P 1 or 2 Family Dwelling-No.of Bedrooms: 3 f 7 ❑City <br /> ❑ Public/Commercial(describe use): ❑Village <br /> ®Town of <br /> ❑ State-Owned <br /> © <br /> III.Type of Permit: (Check only one box on line A. Check box Ak tan <br /> on line B if applicable) Nearest Road <br /> A) 1. I�LNew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to 1 Tax Numbers)L �� <br /> System Tank Only Existin System o? — <br /> B) Permit Number <br /> ❑A Sanitary Permit was previously issued Date Issued <br /> IV.Type of POWT System: (Check all that apply) <br /> XNon-pressurized In-ground ❑Mound <br /> ❑Pressurized In-ground ❑Sand Filter ❑Constructed Wetland <br /> ❑At-grade ❑Holding Tank ❑Single Pass ❑ Drip Line <br /> ❑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 <br /> Required PP 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> (��0 q Proposed Rale(Gals./day/sq,ft.) (Min./inch) Elevatir <br /> ll goo goo I - 196,E y6'Y <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks <br /> New Existing Con- Con- glass <br /> Tanks Tanks trete structed <br /> 6 0o s'�°�, ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersi ed,assume res onsibili for installation of the POWTS shown on the attached tans. <br /> Plumber's Name(print) Plumber's Signature(np stamps): MP/MPRS No. <br /> *�� Number <br /> R1ch" /{a s —1 1 ��Plumber's Address(Street,City,State,Zip <br /> ok >760 #t l 3S W pL5 F rr (.t/...Z <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued <br /> r pr6ved ❑Owner Given Initial Adverse Surcharge F ) Issuin en a mps) <br /> Determination c , �� p - 61 <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />