Laserfiche WebLink
Safety&Buildings Division <br /> Sanitary Permit Application <br /> 201 W.Washington Ave. <br /> PO Box 7302 <br /> In accord with Comm 83.21,Wis.Adm. Code WI 53707-7302 <br /> See reverse side for instructions for completing this application Madison, <br /> (Submit completed form to county if not <br /> Iseonsin Personal information you provide may be used for secondary Purposes state owned. <br /> Department of Commerce <br /> [Privacy Law,s. 15.04(1)(m)] <br /> ess <br /> an <br /> s in size. <br /> Attach com lete tans(to thePecou t umber onl r C to, t ck f reviis on to previous a1 plication 8-1/2 stat Plan I.De Number <br /> County L�. _. _ Stat tary �� <br /> ��UuLocation: <br /> pert L ja,,9n <br /> I.A lication Information-Please Print all Information p ,�11 <br /> Property Ow rName 1/q 1/4,S Os T?7N. or W <br /> V. Lot Number Block Number <br /> r <br /> Property owner's Mai ing Address pp <br /> d F A2 N Q Phone Number (/ Subdivision Name or CSM Number <br /> ity,State Zip Code <br /> Lei, J�W�U (�s/ ) b 8078 <br /> hIP r, ❑City <br /> check one ❑Village <br /> II Type of Buil d• g: ( ) p Town of <br /> 0 1 or 2 Family Dwelling—No.of Bedrooms: -f+hX04 �e <br /> ❑ Public/Commercial(describe use): <br /> ❑ State-owned Nearest Road <br /> a' :V U- <br /> III Type of Permit. (Check only one box on line A. Check box on line B if applicable) Parcel Tax Nu er(s) <br /> - er <br /> A) I. XNew System 2. ❑Replacement 3' Tank On�ement of 4. ❑Addition <br /> nstem o3 Date Issued <br /> System <br /> Permit Number <br /> B) <br /> ❑A Sanitary Permit was orcvjously issued <br /> IV.Type of POWT System: (Check all that apply) ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Non-pressurized In-ground Mr folding Tank ❑Single Pass ❑Drip Line <br /> ❑Pressurized In-ground ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> ❑At-grade <br /> V D►S ersaVTreatment Area Information: Application 5.Percolation Rate 6.System Elevation 7.Final Elevationrade <br /> 1.Design Flow(gpd) 2.R quire Proposed <br /> 3.Dispersal Area 4,Soil Rate(Gals./day/sq../day/sq.t1J (Min./inch) <br /> Required Proposed <br /> 4,10 <br /> Ci <br /> 3 p <br /> #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Total <br /> VI Tank Capacity in Con- Con- glass <br /> Gallons Gallons Tanks trete strutted <br /> Information New Existing <br /> Tanks Tanks Ig ❑ ❑ ❑ ❑ <br /> X 4t.11 <br /> VII Responsibility Statement on s Phone Number <br /> I,the undersi ned,assume res onsibilit for in st flat n of the POWTS show p[MPRS No. ans. <br /> plumber's Name(print) /,f PI mb is Si tur no slam s): G 7 yJd U7 d, <br /> I <br /> Plumber's ddress(Street,City,State,Zip Code) <br /> C � S r/�•S <br /> ,CJ k 7 <br /> VIII County/Department Use Only Issuin Age Sig ature ps) <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) V <br /> 00 {�o <br /> Determination (/�j V �1 <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />