Laserfiche WebLink
Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 k r 4 <br /> Visconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 <br /> Sanitary Permit Application State Plan I.D.// Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide V <br /> may be used for secondary purposes Privacy Law,sI5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information—Please Print Ali Information ys �, <br /> , _ I X C <br /> J U yk <br /> Pro rt Owner's Name Parcel# Lot# Block# <br /> it til v 4 SOYA o - 50 -OR- LIOD <br /> Property O er's Mailing Address Property Location <br /> I I V_L6L sf ' / <br /> / <br /> City,State Zip Code Phone Number Np %.SL Y., Section <br /> VO taiti ' S TO 6 69L 8 3 (circl� <br /> II.Type of Building(check all that apply) T N; RE o <br /> 1 or 2 Family Dwelling—Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial—Describe Use <br /> El State Owned—Describe Use ❑City_❑Village XTownshipo -, give <br /> M.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> ep <br /> A. New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. [I Permit Renewal ❑ Permit Revision El Change of El Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System; Check all that apply) <br /> ❑ Non—Pressurized In-Ground ❑Mound>24 in.of suitable soil X Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ElDrip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dis ersall7'reatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> 300 3� 00 st9 Z <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks I Tanks <br /> Septic)r Holding Tank _/ O00 ,, )i e 49 K <br /> Aerobic Treatment Unit l� liC/ .i-� /` <br /> sing C ) ,S rr••/ <br /> VII.Responsibility Statement-1,the unilersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu ber's Signatur MP/MPRS Number Business Phone Number <br /> /Vela opt r ZLTZz`l17/1- 0 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> g` s- Go d (oS.le`' s Ey 3 <br /> \VIII.County/Department Use Only <br /> Approved El Disapproved Sanitary Permit Fee includes Groundwater Date Issued Issuin Agent Signature(No Stamps) <br /> Surcharge Fee) ' 3C0a 00 _+l/ J <br /> 11 Owner Given Reason for Denial olt9 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81@ x 11 Inches in size <br /> SBD-6398 (R. 01/03) <br />