Laserfiche WebLink
Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 80 Q"L—' T <br /> NVisconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) {i , <br /> Department of Commerce (608)266-3151 0�f 39 q <br /> Sanitary Permit Application State Plan I.D.Number OCN <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide -J <br /> may be used for secondary purposes Privacy Law,sl5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information <br /> g4PoLrs-�i erz <br /> Prope�rty-Owner's Name Parcel# # Block# <br /> O N AV 7 032-Sd2e <br /> Property Owners Mailing Address Property Location <br /> 9707 BxFcy0Did. OciOD&9 �€�., sr 2g <br /> City,State y� ( Zip Code Phone Number /., section <br /> ���'✓:7l) m/V S��oZS 65-1-" ;Dz-`9973 �}.' (circle one) <br /> T I N; RLE or(a <br /> If.Type of Building(check all that apply) <br /> k1 or 2 Family Dwelling-Number of Bedrooms SabdivisionN...., CS <br /> /u�mbber <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑Village PRownship of 9 W 0" <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> �`Vew. System l� y ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing 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 apii <br /> )Non-Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil ❑At-Grade ❑Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑Pressurized In-Ground ❑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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsi) Dispersal Area Required(at) Dispersal Area Proposed(si) System Elevation <br /> qsv 1 '7 1 6q3 m43 91.1-0tt <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 t2 <br /> Tanks Tanks vl! <br /> Septic or Holding Tank /� /6)0 J <br /> Aerobic Treatment Unit <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) I P er S1 at MP/MPRS Number Business Phone Number <br /> xit/AiA pRel-1-17� �aloCoZ � ��;- 2�N-3s�5 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> /617, 3 s. 'GT4T� 3s DvyNrgLl t ) V <br /> VIII.Coun /De artment Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date issued Issuin Signatu Stamps) <br /> 11 Owner <br /> Fee) �J�j�P & /� Ge s <br /> Owner Given Reason for Denial �S�L/ <br /> IR.Conditions of Approval/Reasons for Disapproval <br /> I <br /> JUN1gAim <br /> Attach complete plans(to the County only)for the system on paper not Less than 81/2 x 11 inch"Adin <br /> Tf COUNTY <br /> SBD-6398 (R. 01/03) ZONING <br />