Laserfiche WebLink
Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 h r e <br /> Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Visconsin 1 1 <br /> Department of Commerce (608)266-3151 7 IWI I <br /> Sanitary Permit Application Sae Plan I.D.Number �J <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15.04(1)(m) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print AB Information x10.7/d 5wvr;5-e IV pJ <br /> Property Owner's Name Parcel# Lot# )Z, Block# f,Q. <br /> a <br /> a( ( un, 03 -910,0-0 2- 30o <br /> Property Owner's Mailing Address Property Location <br /> Oa _%, ^__'/., Section <br /> City,State �,/�/1 Zip Code Phone Number <br /> 1• a2 Y i� r -)- 3 . acle <br /> ID.Type o Building(check all that apply) 7 T N; R jyE o(V <br /> t� Subdivision Namaea C$KNumber <br /> P�1 or 2 Family Dwelling-Number of Bedrooms JLN TI$.Q <br /> ❑Public/Commercial-Describe Use <br /> El State Owned-Describe Use ❑City_❑Village*ownehipo ere <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> `t' ❑New System Replacement System ❑Tteatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑Permit Revision 11 Change of El Permit Transfer to New <br /> 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 in.of suitable soil ❑At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑Pressurized in-Ground XHoldingTank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Send Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Die ersaVrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Ex ung <br /> Tanlrs Tanks <br /> Septic rHoldingT i r <br /> Aerobic T catmem Unit <br /> rinsing Chamber <br /> VII.Responsibility Statement-1,the oisdersigned,assume responsibility,for installation of the POWTS shown on the attached plans. <br /> PI her Name( 'nt) P mber's Sign MPIMPRS Number Business Phone Number <br /> Pi <br /> 2Z•S22cf 7/5- <br /> Plumber's Address(Street,City, <br /> ,State,Zip Cade) <br /> CoC. L/r �� UJ I, 's-ry <br /> I.Coun !De artment Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued lssuin g igna o Stamps) <br /> Surcharge Fee) <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of ApprovaMeasons for Disapproval <br /> MAY 1 � 2005 <br /> II I <br /> Attach complete piano(to the County only)for the systan on paper not leu than al nehn in aim CTT COUNTY <br /> ZONING <br /> SBD-6398 (R. 01/03) <br />