Laserfiche WebLink
46� 3�b5�-7 <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> VisconsinSee 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(1)(m)] (Submit completed form to county if not <br /> Attach compTete plans to the county copy only)for the system,on DaDer not less than 8-1/2 x 11 inches in size. state owned. <br /> County State Sanitary ermit Number heck if revision to vious application State Plan I.D.Number <br /> I.Application Information-Please Print all Information Location: <br /> Property er Name <br /> Property Location <br /> Awe <br /> Property Owner's Mailing Address I/4 1/4 S TN, Eor W <br /> Lot Number <br /> :23o0 f c <br /> G. <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> W. _ .54,M K 491 - 7-798 V- 9 <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑ Public/Commercial(describe use): grown 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 /> HA) I. ❑New System 2. �2eplacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numbe � Ap,S stem Tank Onl Existin S stem 04 00 <br /> ❑A Sanitary Permit was previously issued Permit Number Date 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 /> L Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System levation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) 057-'1 Elevation <br /> 45-0Z74-5- S 1 , 2 1io4g - 1o4•0 106.6- 08.4 <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> Ow 10010 13 ❑ ❑ ❑ <br /> boo tow ry _X_ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume res onsibili for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(nos ps)• MP/MPRs No. Business Phone Number <br /> 2�� S1 1s g S <br /> Plumbers Address(S ee[,City,State,Zip Co e) <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agen i to <br /> A-41pprov-d ❑Owner Given Initial Adverse Su <br /> rcharce F]fe) r l /O <br /> Determination g! /J- (J(J <br /> IX.Conditions of Approval/Reasons for Disa r <br /> proval: / / <br /> E' Pa'�f �// ✓��j'lC�fcl eel <br /> C 11 <br /> 11 <br /> SBD-6398 R07/00 <br />