Laserfiche WebLink
Safety and Buildings Division County <br /> yY&Sconsin 201 W. Washington.Ave., P.O. Box 7162 SU.Ct-4 T <br /> Madison, Wl 5 707 -7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application — Sanitary Permit Number --— n <br /> In accord with Comm 83.21,Wis. Adm. Code, personal information you provide ❑ Check if Revision L1t9 030 <br /> may be used for seconds u ses Privacy Law,s15 1)(m) 4.//5 <br /> I- Application Information-Please Print All Information '� Parcel Number State Plan I.D. Number <br /> Property Owner's Name pZO-- <br /> Aci W,- r� <br /> Property O.vner's Mailing ddress Property Location <br /> If C <br /> 10A1 YVjy 70 ti 'A;S,2,0 TyDN, R <br /> City,State JZ,,Code Phone Number Lot Ngmbe� Block Number <br /> Subdiv�is"ion Name �l CSM Number <br /> 5'1f�9 <br /> II.Type of Building(check all that apply) OCity <br /> I or'_Family Dwelling-Number of Bedrooms Tj ❑Village J <br /> ❑ Public! m (Ji <br /> Cornercial -Describe Use Wownship gk14/bq <br /> ❑State Owned Nearest Road <br /> III.Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> A For County use <br /> 1 New 2 [1 Replacement System 3 ❑ Replacement of 6 �� Addition to <br /> System Tank Only Existing System _ <br /> Date Issued <br /> B. i� Check if Sanitary Permit Previously Issued <br /> Permi[Number <br /> IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 Non-Pressurized In-Ground 2111 Mound 47 D Sand Filter 50 D Constructed 1Vedand <br /> 22❑ Pressurized In-Gruund 41 ❑ Holding Tank 48 D Single Pass 51 D Drip Line <br /> 45 D At-Grade 46 D Aerobic Treatment tint 49 D Recirculating 30 D Other <br /> V. Dispersal/Treatment Area Information: <br /> Design Ilow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (MiriAnch) Elevaron <br /> y5D 60 6 &a -7 <br /> 70 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks — <br /> Sepuc or Holding Tank �/y,h _ <br /> Dosing Chamber ��WW <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POW7S shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> cf{fl�P �r/s Z2S$ S 1 1S- g66- 4iS7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 2-7-7 (cc) 14w 35 fB X4-513 <br /> VIII. Count /De artment Use Ofily <br /> Sanitary Permit Fee(include;Groundwawr ate Issued Issuing Agen rgnaru (No ps) <br /> Approved O Disapproved Surcharge Fee)❑ owner Given Initial Adverse � � ) I �-Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> AUG-� 9 'I <br /> 2004 i <br /> SUR <br /> NE7T cou <br /> Attach complete plans(to the County only)for the system on paper not less than 81, size <br /> SBD-6398 (R. 05101) <br />