Laserfiche WebLink
Safety&Buildings Division <br /> Sanitary Permit Application 201 W,Washington Ave. <br /> In accord with Comm 83.21,Wis.Adm. Code p0 Box 7302 <br /> ��seonsin See reverse side for instructions for completing this application Mattison,WI 53707-7302 <br /> Department of Commerce Personal information you provide may be used for secondary purposes (Submit completed form to county if not <br /> [Privacy Law,s. 15.04(1)(m)) state owned. <br /> Attach complete plans to the coun coEX only)for the system,ona er not less than 8-1/2 x I I inches in size. <br /> County State Sanitary Permit N bet ❑Check if revis' to previo applicatio tate Plan 1.D.Number <br /> r.rQ)Cf a <br /> 1.Application Information-Please Print all Inform tin Location: <br /> Property Owner Name Property Location �7 !! yy Q' <br /> 1/4 6/4 S2�i'.J ,N R/(Q or W <br /> Address Lot Number Block Number <br /> Property Owners Mailing Address <br /> f <br /> t �Kc+ v� 5 <br /> W 5fl� N l0 <br /> City,State Zip Code Phone Number UbName or Number <br /> r Sof b r 6 -11I.Type of Building. (check one)❑ 1 or 2 Family Dwelling-No.of Bedrooms:❑ Public/Commercial(describe use): waKL <br /> ❑ State-Ownedd� i i4 <br /> III.Type of Permit: (Check only one box on lineA. Check box on line B if applicable)A) ❑New System 2. q9 Replacement 3. ❑Replacement of 4. ❑Addition toNumber(s) <br /> S stem Tank Onl Existin S ste <br /> B) Permit Number Date Issued <br /> ❑A Sani Permit was previouslyissued <br /> IV.Type of POWT System:(Check all that apply) ❑Sand Filter ❑Constructed Wetland <br /> ❑Non-pressurized In-ground KMound <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dis ersal/Treatment Area Information: 7. <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate TSystom Elevation Elevat on rade <br /> Required Proposed Rate(Gels./day/sq.A.) (Min./inch) 7r <br /> 3o 0 360 a <br /> V1.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fi glass <br /> Information Gallons Gallons Tanks Con- Con- e <br /> New Existing trete strutted <br /> Tanks Tanks . <br /> Tit 1b00 P P ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statementt) <br /> I,the undersigned,assume res onsibili for installation of the POWTS sown on the attached plans. Business Phone Number <br /> Plumbers Name(pin ) Plu rs Signat re( stamps): MP/MPRS No. <br /> �S a-ef e- <br /> X-z / d <br /> Plumbers Address(Street,City,State,Zip Code) <br /> kfl�- tom., <br /> VIII.County/Department Use Only <br /> � ❑Disapproved Sanitary Perms F (Includes Groundwater Date Is ued Issuing g t Sit am (j9 ) <br /> Iproved ❑Owner Given Initial Adverse Surcharge <br /> 11 Determination < J <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br /> OCT <br /> BtURNETT COUNTY <br /> ZONING <br />