Laserfiche WebLink
4�?XJ00 <br /> Sanitary Permit Application Safety&Buildings D i <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Was O ve. <br /> ` ]SCOnsin See reverse side for instructions for completing this application POB <br /> Madison,WI S37 2 <br /> Personal information you provide may be used for secondary purposes (Submit completed form to coun t i <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] <br /> state <br /> Attach com tete plans to the county copy only)for the system,on paper rwwt less than 8-1/2 x 11 inches in size. <br /> County State Sanitaryt N ber Ch revisSon to revious lication Stale Plan L D.Number <br /> I.Appiffication Information-Please Print alf Information �Or Location: <br /> Property Owner Name Property Location 4 <br /> 1/4 1/4,S Ig T V,N,1�IE o W <br /> Property wnet's Mailing Address Lot Nwnber <br /> . L• Z <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> ❑City <br /> ft.Type of Building' (check one) <br /> 2 ❑Village <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: Town of <br /> ❑ Public/Commercial(describe use): <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 /> A) I. ` New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numbe s)/ 03 <br /> System 60 <br /> Tank OnI ExistingSystem <br /> B) Pemlit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POW r System: (Check all that apply) <br /> on-pressurized In-ground ❑Mound ❑ Sand Filter ❑Constructed Wetland <br /> �IN❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(GalsJday/sq.ft.) (Min./inch) Elevation <br /> lie <br /> .vo 40 432 , ? /".9 g <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no stamps): MP/MFRS No. Business Phone Number <br /> LMAi7D ,✓ X2585/ S- <br /> umbels Address(Street,City State,Zip Co e) <br /> 2- 760 3s W�ssT�z Wl. 54$93 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater DatZ!:!LO <br /> ued Issuing Agent SiMaturestamps) <br /> 'Approved ❑Owner Given Initial Adverse Surcharge Fee) E% y 0d,(� L <br /> Determination R d� <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> rL <br /> SBD-6398 R07/00 ' <br /> ta ,i' t c <br />