Laserfiche WebLink
Safety and Buildings utvision t.ounly <br /> 201 W. Washington Ave., P.O. Box 7162 BurnQ7�L / <br /> �visevnsin Madison, W 1 53707-7162 Site Address` <br /> P v en ■Commerce !4// Toa <br /> J' f! <br /> Sanitary Permit Number <br /> Sanitary Permit Application Sann 592 <br /> In accord with Cotrim 83.21,Wis.Adm.Code,personal information you provide •�' / <br /> ma be used for second purposes PrivacyLaw, .04 IHm C1 Check if Revision <br /> 1. Application Information-Please Print All Information Suite Plan I.D. Number O <br /> Property Owner's Namc Parcel Number <br /> JOhnso v7 <br /> Property Owner's Mailing Address Property Location v 1 <br /> / -s60 E/Co.ro du Ss! S ta'u SA W:S d, T VD N. R/to E <br /> City,Stam Zip Code Phone Number Lot Number Bleck Number <br /> Subdivision Name CSM Numhe <br /> 91,107 e_ /1'I,d. SSyH4 763- -75W -ad`/d V. I O Q <br /> II.Type of Building(check all that apply) ❑City <br /> & or 2 Family Dwelling-Number of Bedrooms <br /> ❑Village _ <br /> ❑Public/Commercial-Describe Use @ township OAK/an� <br /> ❑Sure Owned Nearest Road <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicabir) <br /> A' 1 New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> S stem Tank Only Existiolt System <br /> B• ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 Q Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50 Constructed Welland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V. Dis ersaUTreatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) 93. 7 Elevation <br /> 9s•e <br /> etS-D 643 648 . 7 — 9x.0 96 O <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Seel Fiber P(: ;tit <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank X000 - 1000 _Z� Ska.✓ ' X <br /> Dosing Clamber <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for iostallation of the POWTS shown on the attached pL.na. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Numbcr Business Phon:Number <br /> ?le.k 1>le krrs -4Jar� )Q d es/ 716= <br /> Plumber's Address(Street,City.State,Zip Code) <br /> 7700 //. 3S websjeee- W-r _5-gV'/3 <br /> VIII. Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Dart Issued Issuing A ignature <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse 250 op /q� O` <br /> Demtmitution (l �•C.GT .J <br /> U. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper no less than 8112%11 inches in it., <br /> SBD-6398 (R- 05/01) <br />