Laserfiche WebLink
Safety and Buildings Division t:ounry <br /> WW 201 W. Washington Ave., P.O. Box 7162 ���^�!e. J' 4 <br /> isconsin Madison. WI 53707-7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary Permit Number <br /> in accord with Cotton 93.21,Wis.Adm.Code,personal information you provide 4-78417 <br /> ma be used for seen purposes PrivacyLaw,sl 1)(m 11 Check if Revision <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> SOD g <br /> Property Owner's Name Parcel Number 00 <br /> ,8 ^,/%q n� /0112- e- 1-S 4-- J ©.;?a- <br /> Property Owner's Mailing Addresso Property Location <br /> 3oS y7 VC, IJ J694 u W:S& TYON.R /6 E <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> a <br /> / Subdivision Name CSM Numbe <br /> C A r) 6r�d e Inn) SYOC)S, <br /> II.Type of Building(check all that apply) ❑City <br /> , _ <br /> m or 2 Family Dwelling-Number of Bedrooms <br /> ❑Village _ <br /> ❑Pubtic/Commercial-Describe Use 3E!rownship OAK A-i C/ <br /> ❑State Owned Nearest Road / <br /> III.Type of Permit: (Check only one box on line A (numbering scheme forinternal use). Complete line B if applicable) <br /> A. rp( For County use <br /> 1"�New 2 ❑ Replacement System 3 ❑ Replacemem of 6 ❑ Addition to <br /> 5 stem Tank Only Existing System <br /> B- 1 ❑ 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 19 Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Weiland <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 ersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Race System Elevation Final Grade <br /> Required Proposed Race(Gals./Days/Sq.Ft.) (Min./inch) Elevation <br /> �o o Ya so 1 _7 _ �j, � q7, ? <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Sicel Fiber Phaic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Htsldil"`fa"k Sed $0J ? eJ <br /> Dosing Chamber <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached pl:Lns. <br /> Plumber's Name(P ''^t) Plumber's Signature MP/MPRS Norther Business Phon:Number <br /> G��c/w— 1�� �o%t Ge��..� zZ�G �� f Y9 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIIL Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing em egnature n ps) <br /> Surcharge Fee) <br /> C1Owner Given Initial Adverse r0 <br /> Determination �(/ 'V/ll7 Mfr ,J <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plana(lo the County only)for the system an paper not less than 81/2 x It inch.to she <br /> SBD-6398 (R. 05/01) <br />