Laserfiche WebLink
Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W Washington Ave. <br /> PO Box 7302 <br /> Visconsin See reverse side for instructions for completing this application <br /> Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <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)fopthe system,on pape not less than 8-1/2 x 1 I inches in size. <br /> County State Sanitary Permit Number ❑ heck if7isi preeviou application State Plan I.D.Number w <br /> ur'iU e. /� 3 <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location G <br /> D W r o/ G/� /f) /Yl 6/J 6-1/4$-,5 1/4,S..V,?T3R1 <br /> E(or12 <br /> perty Owner's Mailing Address Lot Number Block Number <br /> A o S <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> -Si P..,) � --S-VE 7 2- o p+rWood <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: iZ ❑Village <br /> ❑Public/Commercial(describe use):_ %Town of <br /> ❑State-Owned <br /> Nearest Road <br /> Parcel Tax Number(s gel <br /> O <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. New 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> ystem System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> *Ion-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 /> 1.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(GalsJday/sq.ft.) (Min./inch) Elevation <br /> .3 0 6 0 o d o 0 , 5— 9s%S 97..s-- <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete strutted <br /> Tanks Tanks L <br /> VIII.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(n ps): MP/MPRS No. Business Phone Number <br /> A)Pdc <br /> Plumber's Address(Street,City,State,Zip Code) <br /> .Q 6 X S-1 S//' e --) w T7 �' 72 <br /> IX.County/Department Use Only <br /> ❑Disapproved I Sanitary Permit Fee(Includes Groundwater Date Iss s Sit*na (No stamps) <br /> XApproved ❑Owner Given Initial Adverse Surcharge Fee) �p� <br /> Determination �LJv. �f— , '03 <br /> X Conditions of Approval/Reasons for Disapproval: <br /> ? 20 <br /> BURNED 0 1 <br /> C <br /> SBD-6398(R.07/00) <br />