Laserfiche WebLink
Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> Visconsin See reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 su <br /> Department of Commerce Submit completed form to county[Privacy Law,s. 15.04(1)(m)] ( p if not <br /> I t t <br /> Attach complete plans(to the county copy only)for the system,on paper not lstate owned.) <br /> ess than 8-1/2 x 1 I inches in size. V l <br /> Co Sta Sanitary Permit Number eck if vision to previou application State Plan I.D.Number <br /> ti�N +3 007 a <br /> I.Application Information-Please Print all Information Location: <br /> Prope Owner Name Property Location G <br /> 6 •e-r� �/� /UE1/45rC1/4,5// TyGN,R/'�(or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> -,:?0.3 d y> S�! <br /> City,State // Zip Code Phone Number Subdivision Name or CSM Number <br /> Y3 /j//V. S SGS r — <br /> Uef�rI•oJt ( ) <br /> II.Type of Building: (check one) ❑city <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use): 113-Town of <br /> ❑ State-Owned <br /> Nearest Road <br /> Parcel Taxu�mber(s <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> FB) <br /> 1. ❑New 2. eplacement 3. 11 Replacement of 4. 5. 6Addition to <br /> . ❑ <br /> System System Tank Only Existing System <br /> Permit Number <br /> Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> 96qon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> TI 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 Rats 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.R) (Min./inch) Elevation <br /> 3aa &,�o0 6ev s 9S,9s2 97- 72,2- <br /> VII.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 /> Ste /` rov go,9 k� �J ❑ ❑ ❑ El <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Na/me(print) Plumber's Signature(no stamps):/ MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑7Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issui t Signatu o stamps) <br /> Approved ❑ iven Initial Adverse Surcharge FeeDeion <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />