Laserfiche WebLink
Safety and Buildings Division County <br /> 1201 W. Washington Ave., P.O. Box 7162 6 V&44 7 <br /> 4pisconsin Madison, WI 53707-7162 Site Address <br /> Department of Commerce 3)1q�3 ` <br /> Sanitary Permit Application Sanitary Permit N}, S <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide Check if Revision i(O <br /> maybe used for secondarypurposes Privac Law 15. 1 m <br /> I. Application Information-Please Print All Information g State Plan I.D.Number S <br /> Property Owner's Name Parcel Number <br /> Property Owner's Mailing Address Property Location <br /> SE tti "'A;S 5 T4/ N,R!S <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> �q9/ Subdivision Name CSM Number <br /> �- <br /> II.Type of Building(check all that apply) ❑City <br /> X1 or 2 Family Dwelling-Number of Bedrooms ❑village <br /> ❑Public/Commercial-Describe Use Township G <br /> ❑State Owned Nearest Road <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. I XNew 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> System Tank the 6 El' <br /> B• ❑ Check,if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44)(Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Wetland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑Single Pass 51❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 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 /> -3e)f) 421 43S' 17 '1-7,' (3 rl l <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> (gJzM <br /> Septic or Holding—Tank 5 _ -75-0LE+hCo2L�'J'L� f->•cGtJZ �� <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans, <br /> Plumber's Name(Print) Plumber' ' namre MP/MPRS Number Business Phone Number <br /> U M �r <br /> Plumber's Address(Street,City,State,Zip Code) <br /> /Z-7/3 S- STAlz 00 5(;- 1�.9tigc1� Gt �i �`l� 3f7 <br /> County/Department Use Only <br /> Approved ❑ Disapproved ISanitary Permit Fee(includes Groundwater Date Issued Issuing Agent Signature(No Stamps) <br /> Surcharge Fee) <br /> ElOwner Given Initial Adverse. <br /> Determination <br /> IR. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x Il inch"in size <br /> SBD-6398 (R. 05101) <br />