Laserfiche WebLink
Safety and Buildings Division County <br /> INVi 4111201 W,Washington Ave.,P.O.Box 7162 See r nseonsin Madison,WI 53707-7162 Sanitary.Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 T7 2 2 .75 <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s I5.o4(I)(m) Project Address(if different than mailing address) <br /> L Application Information-Please Print All Information r '^ <br /> Property Owner's Name Parcel# Lot# Y �' ` Block# <br /> !k / r4S'b✓� © ` -- <br /> Property 0 er's Mailing Address Property Location <br /> Sa-o WeS+ SI eta v'e_� I Spt" a <br /> City,State Code 7Phone Number 6'A, Section <br /> tio <br /> n <br /> 3 <br /> ILTY-4 n bi, ?circle <br /> Type of Building(c k all that apply) T3_7 N; R Eor <br /> KL 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑Village(Township of r(ede- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A_ New System <br /> ❑ Replacement System ❑Treatment/Holding Tank Replacement Only C1 Other Modification to Existing System <br /> B. , —� List Previous Permit Number and Date Issued <br /> Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New <br /> LIBefore Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> - <br /> ❑ Non-Pressurized In-Ground N Mound>24 in,of suitable soil ❑ Mound a 24 in,of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.-Dispersal/Treat ent Area Information: <br /> Design—Flow(Pd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sO Dispersal Area Proposed(st) System Elevation <br /> 16. S <br /> Ir N1.Tank Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing PO <br /> Tanks Tanks <br /> Scpnc Holding Tank P <br /> Aerobic Treatment Unit <br /> Dosing Cham )r <br /> VII.Responsibility Statement- 1,[he dersigned,assume responsibility for instillation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) PI mber's Sign tore MP/MPRS Number Business Phone Number <br /> Pe(S "v ZzSu 7/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 6, u,. d `�►' S ics�`r 3 <br /> LVVIII.County/De artment Use Onl <br /> Approved 13 DisapprovedSanitary Permit Fee(includes Groundwater I Date Issued Issuing Signa tamps) <br /> Surcharge Fee) r[ <br /> ❑ 0 3G�Owner Given Reason for Denial I 4 ,(aC 05 <br /> It.Conditions of ApprovaVReasons for Disapproval <br /> Attach complete Plans(to the County only)for the system on paper not less than 81/2 s 11 Inches In size <br /> SBD-6398 (R. 01/03) <br />