Laserfiche WebLink
Safety and Buildings Division county <br /> 20 W. Washington Ave., P.O. Box 7162 <br /> Visconsin <br /> Madison, WI 53707 -7162 Site Address <br /> Department of Commerce --- <br /> Samtary Permit Number ` <br /> Sanitary Permit Application VJ") <br /> In accord with Comm 83.21,Wis. Adm. Code, personal information you provide ❑ Check if Revision 5e�O <br /> may be used for secondary PUM2ses Privac Law.sl .64(U(m) --- <br /> 1. Application Information-Please Print All Information State Plan I.D. Number <br /> 1 <br /> Property Owner's Name Parcel Number <br /> Lisa Gni0!346 <br /> Property Owner's Mailing Address Property Location 6o V�-„ uF i <br /> 6 640 1�aIerl Lk Rd. w <br /> �H 'r: 5 ,� T �f0 N. R/b <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> Subdivision <br /> \Name !/ CSbt Number <br /> �anba. Wj' Scf�3� 7�S- 6r(i_ 73It L�Sm V. t <br /> H.Type of Building(check all that apply) ❑City <br /> I or 2 Family Dwelling -Number of Bedrooms 6 ❑Village <br /> ❑ Public'Commercial -Describe Use QTownship opt k14 .% <br /> ❑ State Owned Nearest Road <br /> f/4 clevt Lk /p� <br /> III.Type of Permit: (Check only one pox online A (numbering scheme for internal use). Complete line B if applicable) <br /> A r For County use <br /> 1 New 2KReplacement System 3 ❑ Repiacamem of 6 ❑ Addition to <br /> S stem Tank Onl Exisdn Svstem __ <br /> B. ❑ Check if Sanitary Permit Previously Issued <br /> Permit Number - Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44pi Non-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Constructed Weiland <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: —A <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Ram System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Miridlnch) 7y.S Elevation <br /> 93,0 <br /> 3 Dp OL . 7P- <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 /> Tank- Tanks <br /> Septic or Holding Tank . - 7r <br /> Dosing Chamber Soo <br /> VII- Responsibility Statement- I,the undersigned,assume responsibility for installation of the PON TS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/—M—PRS Number Business Phone Number <br /> c{}R02D jrJs 2 �` 21Z S S 1 71.5- S66- �S7 <br /> Plumber's Address(Street,City,Stam,Zip Code) <br /> 277 (oo 14w 35 EB �4g 3 <br /> VIII. Cou71DeUse 1 <br /> Sanitary Permit Fee(includes Groundwater Dam issued Issuing t gnature amps) <br /> Approveded Surcharge Fee) p, �Yp <br /> iven Initial Adverse 7t 15-os n (/IX. Condal/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than$112 x 11 inches in size <br /> SBD-6398 (R. 05101) <br />