Laserfiche WebLink
Safety and Buildings Division County <br /> ` <br /> v 201 W. Washington Ave., P.O.Box 7162 euea—gr —11 <br /> rseonsin Madison,WI 53707 -7162 Site A ress <br /> Department of Commerce <br /> Sanitary Permit Application Sanita`Iry�/Perm2it Number //`,-,—{ <br /> In accord with Comm 83.21.Wis.Adm.Code,personal information you provide 3 �o�/ �L�I I� <br /> may be used for second purposes PrivacyLaw,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 /> 037 9,OS, of IDD <br /> Property Owner's <br /> ��I'r' Mailing Address <br /> • �[ Property Location ,t q <br /> ,Z / j4eA-- fI AV. 'A:SZ9' T + N,R 16 <br /> City,State Zip Code Phone Number Lo[Number Block Number <br /> �ne�l/l. ,f_ > A.1�• ✓ 113 ��- '"" �� Subdivision Name CSNf Number <br /> II.Type of Building(check all that apply) ❑City <br /> I or 2 Family Dwelling-Number of Bedrooms ❑village <br /> ❑ Public/Commercial-Describe Use ownship tt�1 5.5 <br /> El State Owned earest Road <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. ) New 2 11Replacement System 3 CJ Replacement of 6 ❑ Additionto For County use <br /> S sum Tank Only Existing System <br /> B• I ❑ 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*fNon-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 rcolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (I Ain.11nch) Elevation <br /> ,�00 4-29 ¢�2 .� 9�s i 9g.a <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 /> Tanks I Tanks <br /> Septic or Holding Tank Ld /DoD �/QR Epp <br /> Dosing Chamber <br /> I <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of he POWTS shown on the attached plans. <br /> Plumber's Name(Priv[) Plumber's Signature MP/MPRs Nu Der Business Phone Number <br /> �4Aoev „✓s - z2S8 s I �/.s- g66- 46-1 <br /> lumber's Address(Street,City,State,Zip Code) <br /> 2-7 7 &0 14w 35 � �48 3 <br /> �VII/I. County/Department Use 1 <br /> &Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing AgenWSgna (N <br /> Fee) <br /> Surcharge <br /> ❑ Owner Given Initial Adverse 4 1 l�J uj ou 1•'I/��O _ <br /> Determination Q( <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> VaNd <br /> DEC <br /> 11 <br /> Attach complete plans(to the County only)for the system on paper not ess than 81/2 x 11 inches in sizeO/ , _ <br /> ZONING V�� <br /> SBD-6398 (R. 05101) <br />