Laserfiche WebLink
wSafety and Buildings Division County <br /> M N 201 W.Washington Ave.,P.O.Box 7162 <br /> iseonsin Madison,WI 53707 -7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15. 1 m ❑ Check if Revision <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> Property Owner's Name Parcel Number <br /> TEWL P14tALL4 S O)2- /Do <br /> Property Owner'sMailing Address Property Location n <br /> 2-15739 FFR)Es R�- 'k '.4;S "T N.R �S <br /> City,State Zip Code Phone Number Lot Number Bl r 2- <br /> Subdivision Name CSM Number <br /> WEBatc2 � W1 . -l3 U <br /> H.Type of Building(check all that apply) ❑City <br /> X 1 or 2 Family Dwelling-Number of Bedrooms 3 ❑Villa e <br /> B <br /> ❑ Public/Commercial-Describe Use *ownship SJ4GKSOIJ <br /> ❑State Owned Nearest Road <br /> N• 345S Lk A. <br /> III.Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> 1 1 �New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> S 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'K' ikon-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Constructed Wetland <br /> I <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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) /�� �1. i El vation <br /> 900 q00 E9 .2 q6.Z <br /> VI.Tank Info Capacity in Torsi Number Manufacturer Prefab SiteStee( Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Ex a inng <br /> Tanks Tanks <br /> Septic or Holding Tank 000 �.. 1000 <br /> va i 0 <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MFRS Number Business Phone Number <br /> cfFA�ev r/s ZissS 1 71 g66- 41S? <br /> Plumber's Address(street.city.state,zip code) <br /> 277 !oo 4 <br /> VIIL County/Department Use Ofily <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agent Signature(No Scamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse <br /> . <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> �I <br /> Oct t 3 2003 <br /> Attach complete plans(to the County m 1 s than 81/2 x 11 Inches in size <br /> ZONING <br /> SBD-6398 (R. 05101) <br />