Laserfiche WebLink
Safety and dwlamgs DIVI51an county 201 W.Washington Ave.,P.O. Box 7162 <br /> .`1 Isconsin Madison,WI 53707-7162 Site Address <br /> Department of Commerce ER �. <br /> Sanitary Permit Application Sanitary Permit Number <br /> in accord with Comm 83.21,Wis.Adm.Code,personal information you provide44 S 7*3 C <br /> may be used for secondary purposes Privacy Law,05-040)(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 /> Son SIJ e Min 02-q-q*35- of 00 <br /> Property Owner's Mailing Address Property Location <br /> t-i (o4 Ljncor_.-a AVS. OE% .SEyt:S 17_ T M N.RIW ,) <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> ( n Subdivision Name CSM Numix <br /> ST rGwQ >y). 551 Ot 4si -(, 1,-9o4q Li sie?nfy S <br /> 13.Xype of Building(check all that apply) ❑City _ <br /> 1 or 2 Family Dwelling-Number of Bedrooms 3 ❑Village _ <br /> ❑Public/Commercial-Describe Use Otownship 12AA5y, <br /> ❑State Owned Nearest Road <br /> uel L I PA L r✓te42,L yhtf. <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for.internal use). Complete rde B if a plicabll:) <br /> A. I R New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For Cotutty use <br /> system I I Tank Only Existit S stem <br /> B. ❑ Chock if Sanitary Permit Previously Issued <br /> Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme i5 for internal use) <br /> 44;W Non-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Constructed Wetland <br /> /(Z 02F"w 3',cbs. <br /> 22 ElPrtsstrized 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. Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Race System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> (P`�3 <br /> 45o U.56 ,7 ma'-pin 88.o > 93.S' <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Sigel Fiber Pll ;tie <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or _ X <br /> � a <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,fhe undersigned,ass*me responsibility for installation of the POWTS shown on the attached ph ns. <br /> Plumber's Name(Print) s Signa MP/MPRS Number Business Phons Number <br /> M&K SEPTIC & EXCAVAP <br /> Plum <br /> SP )MI <br /> 5102 <br /> VIII. Count a artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Signature(No n ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse <br /> Determination J ✓ (�/� 7 <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 61/2 x 11 inch"in size <br /> SBD-6398 (R. 05/01) <br />