Laserfiche WebLink
Safety and Buildings Division County <br /> �u/nc <br /> 201 W.Washington Ave.,P.O.Box 7162 Site Address <br /> Madison,WI 53707-7162 <br /> isconsrn d(e w �;.se* t�Ae A <br /> Department of Commerce Sanitary Permit NINW3 ber <br /> _ `� <br /> Sanitary permit Application <br /> personal information you provide ❑ Check if Revision r <br /> In accord with Comm 83.21,Wis.Adm.lode.Peat Law,s15. 1)m V 1 <br /> ma be used for secord State Plan I.D.Number <br /> I. Application Information-Please Print An Information A 0 <br /> VJ Parcel Number <br /> Property Owner's Name oa y- 3 f,i - 0,1- you w <br /> fJ L&, 'F�Pcaf <br /> Pit,w� d- s^'e�Y[^ Property Location <br /> Property Owner's Mailing Address 1, ! n /� t e1 t <br /> ,6 ,4:S T 3/I� N,R <br /> a60So25 Phone Number Lot Number 1Q�xcKNumber <br /> Zip Code 6ov`L- <br /> City,State <br /> Subdivision Name CSM Num r <br /> w T <br /> 5y90 S- Z 2r )QB <br /> 11.Type of Building(check an that apply) <br /> ❑City <br /> Number of Bedrooms ❑V81age <br /> or 2 Family Dwelling- ownshiA u 3 k <br /> p <br /> ❑public/Commercial-Describe Use Nearest Road,// <br /> El State Owned (•t).1, St i-f <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> p' For County use <br /> 1 11aew 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to <br /> Tank Ord Existing system Date Issued <br /> S stem permit Number <br /> B. ❑ Check if Sanitary Permit Previously Issued <br /> IV.Type of Permit' (Check all that apply)(numbering scheme is for internal use) 50 Constructed wetland <br /> 21❑ Mound 47❑ Sand Filter <br /> 44Non-Pressurized In-Ground 51❑Drip Line <br /> 41❑ Holding Tank 48 El Single Pass <br /> 22❑ Pressurized In-Ground 30❑Other <br /> 45 11 At-Grade 46❑Aerobic Treatmem Unit 49 El Recirculating <br /> V.Dis ersal/Treatment Area Information: Percolation Rate System Elevation Final Grade <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Ft.) (M /Inch) Elevation <br /> Required Proposed Rate(Gals./Days/Sq <br /> 3co 9029 y3s, y . 7 <br /> 9`f�s 9�•� <br /> Ntmtber Manufacrurer Prefab Site steel Fiber Plastic <br /> Total <br /> VI.Tank Info Capacity in Concrete Constructed Glass <br /> Gallons Gallons of Tanks <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank ',SU - 957> <br /> µ)tYSv- Cp nt rGtC <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the ppWTS shown on the attached plans. <br /> MP/MPRS Number Business Phone Number <br /> Plumber's Name(Print) Pitunber's Si tore 97 6a <br /> pis-Y6a- <br /> DOA Re"etemanii <br /> Plumber's Address(Street,City,State,Zip Code) <br /> � /31s8 fi�•y�trt•nt , c✓s SypY3 <br /> P.o. 6 x <br /> VIII. Count Me artment Use Onl Date Issued Issuing Agent Sign( S ps) <br /> Sanitary Permit Fee(includes Groundwater <br /> Approved ❑ Disapproved Surcharge Fee) j-_1 p� `� <br /> ❑ Owner Given Initial Adverse r tJ()• r <br /> Determination 7� / //44 a A/ <br /> IX. Conditions ofp�pprov�r�res for2�pr�al� � � � 1 ./ � /7?r' <br /> l <br /> Q n n <br /> / Attach complete plana(to the County only)for the system on paper not less than 8112 x 11 inch"in size <br /> SBD-6398 (R. 05/01) <br />