Laserfiche WebLink
Sanitary Permit Application Safety&Buildings Division <br /> Asconsin <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W Washington PO Box ve.See reverse side for instructions for completing this application Madison,WI 5 Box 7302 <br /> Personal information you provide may be used for secondary purposes <br /> Department of Commerce [Privacy Law,s. 15.04(lxm)] (Submit completed form to county if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> Coon State SanitaryPenni Number LlCheck if revision to previous application State Plan I.D.Number <br /> b� tv F+l 42.37? <br /> I.Application Information-Please Print all Information Location: -_-- _ <br /> Propeerrtty'Owe�n])er��rN�'ame -y^�) PropertyLocation )rAf 6/O <br /> -20 <br /> e-7o IV -i UtC1K ! ft C ✓E U (. �Yb� -�1/45101/4,S1 T ! ,N,Rt*(or)JO <br /> Property Owner's Mailing Address Lot Number Block Number <br /> Do $ P41Y wr 01?trk C 0tL - WE ' <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> s 2s <br /> I1I.T pe of Building: (check one) ❑cI <br /> t 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑Public/Commercial(describe use):_ Town of <br /> ❑State-Owned J W 6F 5 <br /> Nearest Road <br /> Parcel Tax Number(s) 03Z'9200'DZ laCO <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. XNew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> (Non-pressurized In-ground 0 Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rale 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(GalsJday/sq.ft.) (Min./inch) Elevation <br /> 7.5VI150 . 7 97-5- <br /> VII. <br /> I.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> /DOd levo Owe wanalz Co11 1 .❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> SPY A3ao6 / 463s- <br /> Plumber's Address(Street,City,State,Zip C e) <br /> S-4 /?/fV46Z- /2 )?0/¢ �`•Go [e,, �o <br /> IX.County/Department Use Only <br /> ❑Disapproved I Sanitary Permit Fee(Includes Groundwater Date Issued Issui Signa o stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) T )y� <br /> Determination � cC J�, " <br /> X.ConditioA -ns of Approval/Reasons for Disapproval: <br /> l� <br /> APR,2 9 3 <br /> BURNE7.T.COUNTY <br /> SBD-6398(R.07/00) <br />