Laserfiche WebLink
Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 , / 0 e— <br /> on,Madison,W153707-7162 Sanitary PerrnitNumber(tobefilled inbyCo.) <br /> De artment of Commerce (608)266-3151 -.J.{Z514 r/ <br /> Sanitary Permit Application State Plan IID.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(I)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All In r ation3�86 / <br /> Property Owner's Name Parcel N Lot N Block N <br /> e /J G 44 0 ,20 3,-,17 e 6 5106 <br /> Prop"Owner's Mailing Address Property Location y <br /> A, Section -2 / <br /> City,State Zip Code Phone Number-7 <br /> N r �5 /� 3 �'00 / `�� d ucleo <br /> T�N; R�E or6) <br /> 1��± <br /> 1,.Ty of Building(check all that apply) 2 yWldivisimNeme CSM Number <br /> 13ior2 Family DwellingNumber of Bedrooms-- :3 ��O Gi Li <br /> Cm <br /> ElPubliGCommercial-Des scribe Use rl•W,'J, <br /> ❑State Owned-Describe Use ❑City_❑Villag T wn�p o r� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) �V\J <br /> A. ❑New System placement System TrealmenUl loldingReplacement Only ❑ Other Modification to 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 Wetland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peal Filler ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filler ❑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(so Dispersal Area Proposed(so System Elevation <br /> o " 7 y.;2 5 vsdi 9 5-0 <br /> VI.Tank Info Capacity in TotalNumber Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks/\ Tanks <br /> Septic or Ho itnl&'S Turik <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(P nt) Plumber's Signature MP/MFRS Number Business Phone Number <br /> ti �4dr (4/s/o/ Gr/",. - 7G 9/ y6— <br /> Plumbe�r'ss Address(Street,City,State,Zip Code) <br /> /� o X -z-- -. ',i- e • ) 4",..77- YJ, 7z <br /> VIII County/Department Use Only <br /> Approved ❑ Disapproved Sanitary Penni[Fee(includes Groundwater Date Issued r Issui A igna o Stamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Reason for Uenial �CrJI/ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plana(to the County onl))for the system an police not less than 81/2 z I I inches in size <br /> SBD-6398 (R. 01/03) <br />