Laserfiche WebLink
Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O.Box 7162 <br /> Vsconsin Madison,W 153707—"1162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 i/7p,5g./ - -- <br /> Sanitary Permit Application State PlPlan IOD Numbe`rf" 1� <br /> In accord with Comm 83.21,W is.Adm.Code,personal information you provide C7 <br /> may be used for secondary purposes Privacy Law,sl 5.04U)(m) Project Address(if different than mailing address) r <br /> 0 <br /> L Application Information—Please Print All Information7 35 �e�QI / n�1 <br /> iProperty Owner's Name Parcel is `l Lot H / T Block H <br /> W�yy � u�ASov" b30'��t -�`f16o0 <br /> Property Owner Mailing Address ` Property Location 60V <br /> ,r tl W 3 <br /> `C)' C' Sad- V,. /., Section <br /> City,State 11 Zip Code Phone Number <br /> 1r W r V7g7� 7/S /(circle Pei <br /> eN l v t D T I �(� <br /> N', R E or <br /> T, Q_ <br /> Il.'fype of Building(check all that apply) <br /> SNumber <br /> P(I or 2 Family Dwelling—Number of Bedrooms <br /> Subdivision Name CSM Number <br /> [Public/Commercial—Describe Use — _ e�' Ivis�ion`V <br /> - State Owned—Describe Use []City ❑Village Township of JII-P r� <br /> l Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> "A ri New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. V Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Ty e of POWTS System: (Check all that apply) <br /> Non—Pressurized In-Ground ❑ Mound>24 inof suitable soil ❑ Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter — <br /> Constructed Wetland U Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter �. <br /> Rcc ren!ating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) -- —� <br /> V. Dis ersal/freatmenl Area Information: _ <br /> Design Flow(gpd) Design Soil Application Rate(gpdsq Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> yS0 ,-7_ - lvSo <br /> ----- <br /> Vl.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber PlesOe <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks I Tanks <br /> Scptic Holding Tank 1000 ( W le&er <br /> A <br /> Aerob,o Treetmcnt Unit <br /> Dosing Chamber --- <br /> VIL Responsibility Statement- 1,the 4ndersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's( Name� (Print) P tuber's Sign ire MP/MPRS Number Businessf-Phho�ne Number <br /> �e lS rzbCr r zzsu '7f� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7KqS Co �l lc r, c-t1. S�8r3 <br /> VI IL Coon /De artment Use On <br /> Approved F1 Disapproved Sanitary Permit F'ee(includes Groundwater Date Issued Issuing nt y 6nature tamps) <br /> Surcharge Fee) ,S�O /D_/,1 <br /> Owner Given Reason far Denial p( <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plum(to the County only)for the system on paper not leas than 91R x l l inches in site <br /> SBD-6398 (R. 01/03) <br />