Laserfiche WebLink
Safety&Buildings Division <br /> Sanitary Permit Application 201 W.Washington Ave. <br /> Asconsin <br /> In accord with Comm 83.21,Wis.Adm. Code PO Box 7302 <br /> See reverse side for instructions for completing this application Madison,WI 53707-7302 <br /> Personal information you provide may be used for secondary purposes (Submit completed form to county if not <br /> Department of commerce [Privacy Law,s. 15.04(1)(m)) state owned. <br /> Attach com lete laps to the county co onl fpulk <br /> tn paper t less than 8-1/2 x 11 inches in size. <br /> County Stat anitaV�ocr Permit Number vious a lication State Plan I.D.Number Location: Y <br /> I.Application Information-Please Print all Information Property Location <br /> Property Owner Name <br /> �. 114,ST ,N,RorW1/4 <br /> CAf Lot Number B� <br /> Property Owner's Mailing Address •/ / <br /> Phone Number Subdivision Name or CSM Number <br /> L 10 <br /> City,State Zip Code <br /> RAnhS W� 54 4o s (� - 4 26 Kis <br /> ❑city <br /> II.Type of Building: (check one) ❑Village <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: �� �Itt `$Town of <br /> )! Public/Commercial(describe use): /1/ <br /> ❑ State-Owned Nearest Road <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> to Parcel T Number(s)s) M <br /> A) 1. New System 2. ❑Replacement 3. �ank Only <br /> of 4. ❑Addition tem � W <br /> System Date ssued <br /> Permit Number <br /> B) <br /> ❑A SanitaryPermit was reviousl issued <br /> IV.Type of POWT System:(Check all that apply) ❑Sand Filter ❑Constructed Wetland <br /> ❑Non-pressurized In-ground Mound <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At- de ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dis ersal(Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application Minanch on Rate 6.System Elevation Elevation Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) ( ) <br /> 4� /.0 98 s o. s <br /> VI.Tank Capacity in glass <br /> Total #of Manufacturer Prefab Site Steel Fi Plastic <br /> llons Gallons Tanks Con- Con- <br /> Information New Existing crete structed <br /> Tanks Tanks <br /> Tanks ❑ ❑ ❑ ❑ <br /> &D6 4 ❑ ❑ ❑ ❑ <br /> 1250 1250 I <br /> VII.Responsibility Statement <br /> I,the undersi ed,assume res on ibilinvy for installation of the POWTS shown on the <br /> No. Business <br /> Tans. Business Phone Number <br /> Plumber's Name(print) Plumber's Signature(no stamps): <br /> c+f�iRO k/el '►4«A ?_?SSBI /S-866- 4157 <br /> lumber's Address(Street,City,State,Zip ode) <br /> 2,7 7&p14 WV Z6 sirg 141. S403 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued [ssurn gent Signature(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination / ✓✓�CCC.d����C <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />