Laserfiche WebLink
cr_�4 MAP <br /> Sanitary Permit Application Building, DIv;,ion <br /> �` In accord with Comm 83.21. Wis.Adm. Code 201 �� \1'ushmgton Avc <br /> 'Wi7F? 7j7ieSee reverse side for instructions for completing this application PO l3uv 7102 <br /> � rsonal information you provide may be used for secondary purposes Madlstttr. t,�l �,'(1%-?i0? <br /> [Privacy Las%. s. 15.04(1)(m)) (Suhmit completed firm Io crninn it not <br /> \.Hach complete plans(to the county copy only)for the system.on Dapernot less than 8-1/2 x I I inches in size slatc <br /> Stair Sanit ry Permit Number heck il'rpvision to reviou application State Plan I. D Nwnber <br /> 1. Application Information - Please Print all Information TriT Location: <br /> Propcm (twiner Hann• <br /> Propert} Location <br /> Tm <br /> I'ropernAtailineAddress &JI1/4 /lcdll4.S3 l 1,1b,N,R 1/4, <br /> u <br /> _ Uu�ner� : ss <br /> Lot Number Block Number <br /> /O F 00 /,go <br /> Cttc..Slair Zip Code Phone Number Subdivision Name or CSxt Number <br /> / ,q /e ROVE Inrn SS3to47 ( 7G3 ) a <br /> II Type of Building: (check one) ❑City <br /> ,2' I or 2 Family Dtaciting-No. of Bedrooms: Z. ❑Village <br /> :1 PubhUCommercial (describe use): , Z-fown of <br /> State-owned <br /> III Type of Permit! (ChSCO I/ <br /> eck only one box on line A. Check box on line B if applicable) Nearest Road <br /> jc��boi5 <br /> A) 1 Z \c S%s(em 2. ❑ Replacement 3. ❑ Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank OnIN Existing System z _ V//74/a 3_ o <br /> ermit <br /> B) PNumber Date Issued <br /> ❑ A Sanrtar% Permit teas previously issued <br /> IV. Type of POWT System: (Check all that apply) <br /> 1Non-pressurized In-ground Grfh�. beE r,S ❑ Mound ❑ Sand Filter ❑ Constructed Weiland <br /> ❑Pressurized In-erou"d ❑ Holding Tank ❑Single Pass ❑ Drip Line <br /> ❑ At-grade ❑Aerobic Treatment Unit ❑ Recirculating ❑ Other: <br /> V Dispersal/Treatment Area Information: <br /> I. Design Flogs (gpc') 1. DispersalArea 3. Dispersal Arta 4.Soil Applications7crete <br /> ate 6.System Elevation 7 Final Gradc <br /> Required Proposed Rate(Gals./day/sq.fl.) E=levation <br /> 300 �So 6/ • 7 VI Tank Capacity in 'Total 4 of ManufactureSite Steel Fiber- Plastic <br /> Information i Gallons Gallons Tanks Con- glNew Existing structed <br /> Tanks Tanks <br /> S.T.a ri" ioo 80o SOD / �KNtJ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ O ❑ <br /> VII Responsibility Statement <br /> 1, the a dersiened. assume res onsibili[ for installatio f the POWTS shown on the attached plans. <br /> Plumber' <br /> ' 6�1JYIYlatttr o stamps): <br /> MPjjtWNo. � <br /> Business Phone Number <br /> N66228 as 'IF7 <br /> Numbers ` (r1SP00 iS b48b1 <br /> 715-Ork 7w <br /> VIII County/Departmen 'se <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing t Signal re( 'o tamps) <br /> lrA-pproved l ❑ Owner Given Initial Adverse Surcharge Fee) <br /> Determination �V' j ig�O <br /> IX. Conditions of Approval/Reasons for Disapproval: <br /> MAY — 1UUI li <br /> 8,Jrr CaUIUT"Y <br /> ZOINING' <br /> �iin-6;qs iR 07iui, <br />