Laserfiche WebLink
Safety and 13utldtngs Division co 1,ty <br /> NVisconsin <br /> 201 W. Washington Ave., P.O. Box 7162 <br /> Madison, WI 53707—7162 Site Address "— <br /> Department of Commerce ���'� a — �� a <br /> Sanitary Permit Application Sa is Permit Number <br /> -7r�In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may secondary <br /> be used for sepurposes PrivacyLaw,s15. 1)(m C ck if Revision <br /> I. Application Information-Please Print All Information St1te Plan I.D.Number p <br /> Property Owner's Name <br /> Parcel Number <br /> Property Owner's Mailing Address L / �/} Q Property Location — <br /> F /' A 6 / 7Y V L A;S� T N.RCity,State Zip Code Phone Number LIA <br /> Number Black;lumber <br /> ivision Name C— sm beN111 ry SSI D �S� 'o��� 5 y�iI, COY 4 <br /> U.Typt of Building(check all that apply) <br /> �j ❑City <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms 7 <br /> - <br /> ❑PubliGrn <br /> Comercial-Describe Use ❑VillageP Z <br /> D❑Stale Ownedownshi <br /> Nearer ad <br /> III.Type of Permit: (Check only one box on line A(numbering scheme forinternal ase). Complete line B if applicable) <br /> A. I ❑ New 2Replacement System 3 ❑ Replacement of 6 El Addition to For County use <br /> S stem Tank I Existing System <br /> B. ❑ Check if Sanitary Permit Previously Issued Pernut Number Date Issued <br /> IVT <br /> 4 <br /> 44 of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 4Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Welland <br /> f <br /> 22 El Pressurized[n-Ground 410Holding Tank 48 11 Single Pass 510Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unlit 49❑Recirculating 30❑Other <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed ^ Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Si eel Fiber ph,mc <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holdins Tank <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached phns. <br /> Plu tar's Name( int) mber's Sig re MP/MPRS Number <br /> Business Phone:Number <br /> e o � ��s 35 a?6a- <br /> Plu ber's Ad rets( t,City,State,Zip C e) <br /> 5'r a � - c « ( :5-til 0 <br /> VIII. Count /De artment Use Onl <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing eni gnature Stau ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse � �� <br /> Determination J J <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> ��L 1 <br /> BURNS 6 <br /> Attach complete plans(to the County only)for the system on paper not less than 31/2 x I t inches in sue <br /> ZONING LINTY <br /> SBD-6398 (R. 05/01) <br />