Laserfiche WebLink
Sanitary Permit Application Safety&Buildings Division <br /> ' In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> N ASCO M Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce Submit completed form to <br /> [Privacy Law,s. 15.04(1)(m)] ( P county if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x 1 I inches in size. <br /> County State Sanitary Permit Number ❑Check if revision to previous application State Plan I.D.Number <br /> 83 <br /> I. Application Information-Please Print all Information Location: <br /> reny Oer Nametyonu �1/4 1/4,ST✓z7,N,R/ or)W Cmoperty Owner's <br /> /Mailing Address <br /> Lot Number Block Number o 1 <br /> ��(i tG� /✓E�H- �'�l A r✓ !-cJ:i.l r— �Ff/^� N <br /> city,State Zip Code Phone Number <br /> Subdivision Name or CSM Number <br /> II.Type Buil ng: (check one) ��// p Cary � I +•tee <br /> 41�--I or 2 Family Dwelling-No.of Bedrooms: rx ❑Village <br /> ❑Public/Commercial(describe use):_ I Town of <br /> ❑ State-Owned A`p�'� 4 e <br /> Nearest Road S <br /> i <br /> Par el Tax Num s) O 3 b <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. New 2. ^Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Dau Issued <br /> A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground 1$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.Dispersrea 3.Dispersal Area 4 <br /> al A .Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> pe> vC 6 <br /> 6 <br /> 6 e) (1-1 <br /> VII. Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con. Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> �,q�,� i ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installat' n of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plpm 's S' nater no scam ): JMPRS No. Business Phone Number <br /> d V d 7 6 7/s Y7a? -o�73s— <br /> Plumbers ddress(Street,City,State,Zip Code) <br /> n 4 LA c � �1 5-y A — <br /> IX.County/Department Use Only <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issui gen nater o stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) r <br /> Determinationp�OQ. Q / r0 <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> l <br /> SBD-6398(R.07/00) <br />