Laserfiche WebLink
ON COMPUTER/SCANNED <br /> Safety and Buildings Division County, <br /> 201 W.Washington Ave.,P.O.Box 7162 g y r k) L' <br /> Visconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> De artment of Commerce (608)266-3151 5,5I 3 5 <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide tlL`2 ie V I C�) <br /> may be used for secondary purposes Privacy Law,s15 04(1)(m) Project Address(if different th�ry mailing address) <br /> I. Application Information—Please Print All Information <br /> 3� tlK RJ <br /> 'rrT <br /> Property Owner's Name Parcel# Lot# k# <br /> 0 -7-c>39,. <br /> 7-o3`t o?•371f1// <br /> ProPropertyOmer's Mailing Address Property Location P'_Yo r t <br /> g7 <br /> a� y9071 s '/4, _1114, Section . <br /> City,State Zip Code Phone Number � <br /> c / /rI -s-6-087 AY3 T JZN, R�ircle,° �� <br /> J <br /> II.Type of Building check all that apply) <br /> P4-pr 2 Family Dwelling—Number of Bedrooms U!p <br /> *60 1 U -7 CSM Number <br /> ❑Public/Commercial—Describe Use V <br /> ❑State Owned—Describe Use ❑City ❑j�Vii�77�gage C6Townshipo <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) _ <br /> A. ANew System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> y El System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> ❑Non—Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑Mound<24 inof suitable soil ❑At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑Pressurized In-Ground I�Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dis ersal/rreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Area Required(so Dispersal Area Proposed(st) S)st�Elevation <br /> ©o e' _ <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> & t�r Holding TankrO0 ,(�0 <br /> Aerobic Treatment Unit i7 <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MPIMPRS Number Business Phone Number <br /> , A- �5461.4 �e G zz6 y -7 <br /> 7 / `1y?_ � � <br /> h4 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> SY97�2 <br /> VIII.Countv/Department Use Ord <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued I in gfnt re(No Stamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Reason for Denial M N.rl <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> hnow4m,45 arc not 1110((646( £to be In �>� dcb ?,Ist" of SPlitir ,�AA otit FIRMS r <br /> ,$Uvne6E CcaA.rt/ o(AW A•g 19, 2oa9 <br /> Anach complete plain(to the County only)for the system on paper not less than 812 x 1 t inches in size <br /> SBD-6398 (R. 01/03) <br />