Laserfiche WebLink
Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> ��seonsin PerSee reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned.) Q <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x i 1 inches in size. <br /> County State Sanitary Permit Number EXhec i revision top vious application State Plan L D.Number <br /> wCne 7/ c 14- <br /> 1. <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name // / Property Location <br /> At�Zee �e � 6 r Lac mac 7,�' S�/4 4JI -5A,s zT ,N,R (or w <br /> Property Owner's Mailing Address Lot Number Block Number <br /> Cl State / Zip Code --[Phone Number Subdivision Name or CSM Number <br /> Il.Type of Building: (check one) ❑City <br /> ❑ I or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ 'Q Town of <br /> ❑State-Owned / 142d``e z4elc <br /> 79cr 'e L,E �Cr <br /> r(s)�3yi3�2 ��, <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Parcel Tax u be <br /> A) 1. JTNew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground ,J31 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 Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required` Proposed r Rate(Gals./day/sq.ft.) (Min./inch) q Elevation /dry <br /> VII.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 /> r �I ❑ ❑ ❑ ❑ <br /> l ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu er s Name/(priPlumb s Signa re( tamps): MP/MPRS No. Business Phone Number <br /> 0��1 S <br /> s o I�S6�S ,.7iS 6��-ZsO� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved I Sanitary Pemut Fee(Includes Groundwater Date Issued IssuMA - nature tamps) <br /> I�Approved ❑Owner Given Initial Adverse Surcharge Fee) a/ ,/ / r <br /> Determination c� U ��y <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />