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 /> V iseonsin personal infomtation you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department or Commerce [Privacy Law,s. 15.04(I)(m)] (Submit completed form to county if not <br /> state owned. <br /> Attach complete plans to the county copy only)for e system,on paper of less than 8-1/2 x 11 inches in size. <br /> County State SanP 't Number ❑ k r izFFsiio to revio pplication State Plan I.D.Number UI <br /> r7Q C) <br /> I.ApAcation Information-Please Print all Information Location: <br /> Property Owner Name Property Location �J <br /> Via L 1/4 1/4 S Ja T N /E or W <br /> Property Owners Mailing Address Lot Number Block Number <br /> 4 o ACRKS <br /> City,State I Zip CodePhone Number Subdivision me or CSM Number <br /> 4oZ o �2 N 1f(nl til <br /> II Type of Building: (check one) ❑City <br /> 54 I or 2 Family Dwelling-No.of Bedrooms: ,Cillage <br /> ❑ Public/Commercial(describe rue): 'Town of / <br /> ❑ State-Owned WN <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1 1. Mew System 1 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Num er(s) <br /> System Tank Only Existine System 0I ko <br /> $) Permit Number Date Issued <br /> ❑A Sani Permit was previouslyissued <br /> IV.Type of POWT System:(Check all that apply) <br /> W9on-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other. <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(GalsJday/sq.ft.) (Min./inch) Elevation <br /> Aso 43 48 11 '� 9 3 -7 q7. 4 <br /> VI.Tank Capacity inTotal #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete strutted <br /> Tanks Tanks <br /> mc ?91 _ 1% 1 1 <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber'sName(print) Plumbers Signature(no a ): MP/MPRS No. Business Phone Number <br /> 11ANZp �S gs1 iS- <br /> Pl bees Address(Street,City, tate,Zip C ) <br /> 2� tA Sd-$ <br /> VIII.County/Department U e Only <br /> y� ❑Disapproved Sanitary P ee(Includes G ndwater Date I ued Issuing Agjr s) <br /> yq Approved ❑Owner Given Initial Adverse Surcharge Fee <br /> �" Determination 4e J <br /> IX.Conditions of Approval/Reasons for Disapproval• <br /> SBD-6398 R07/00 <br />