Laserfiche WebLink
Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> /seonsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce Submit completed form to coup <br /> [Privacy Law,s.15.04(1)(m)] ( P t9 if not <br /> state owned.) r <br /> Attach complete plans to the county c onl for the system on paper not less than 8-1/2 x 11 inches in size. <br /> 4-1 <br /> County L State Sanitary P4 01�t Num •O)Check if revisi to previous application State Plan I.D.Number t�t� <br /> 4 LL <br /> I.Application Information-Please Print all Inform 'on Location: ._y <br /> Property er Name Property Location 1 (� <br /> -0-0 e— 1/4 1/4 T ,N,Rcx�C or W V <br /> Property Owner's Mailing Address te Lot Number �IuckAiwaber <br /> 7 S'�oZ 1—�i`o.trfi r <br /> City,State ,Zip Code Phone Number SubdIONSUGote or CSM Number <br /> II.Type of Building: (check one) ��77 ❑City <br /> lir, I or 2 Family Dwelling-No.of Bedrooms: s� ❑Village <br /> ❑ Public/Commercial(describe use): CgTown of <br /> ❑ State-Owned �9 S0" J <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest <br /> A) 1. ❑New System 1 2. JdReplacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(!s) <br /> System Tank Only Existing System O/ P /p <br /> B) Permit Number Date Issued <br /> 13A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System:(Check all that apply) <br /> ` Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑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 Arca 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.Sysiem Elevation 7.Final Grade <br /> Required Proposed Rate(GalsJday/sq.ft.) (Min./inch) Elevation <br /> '700 6e 80, <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 /> t �/G 000 /DO(J I <br /> ❑ ❑/tJ0/`CeJesc'C2 E3 ❑ <br /> ❑ ❑ ❑ ❑ 4+_ <br /> VII.Responsibility Statement <br /> the undersigned,assume rem2n)hllity for installation of the POWTS shown on the attached plans. <br /> Plumbees Name(print Plumber's Signature(n ): MP/MPRS No. Business Phone Number <br /> 04e 4 Sldf <br /> Plumbers Address(Street,City,State,Zip Code) <br /> ,BOX S/ erj <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Feg,(Includes Groundwater Date I u Issuing Ag Si <br /> t-Approved E3 Owner Given Initial Adverse Surcharge Fee) 41 �Qa /oO , <br /> Determination -[� <br /> IX.Conditions- <br /> off Approval/Reasons for Disapproval: <br /> SBD-6398 R07M <br />