Laserfiche WebLink
Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 tti✓a>!!� <br /> Visconsin Madison, )1 6-315 -7162 Sanitary Permit Number(to be filled in by Co.) <br /> (608)266-3151 7 32 � <br /> Department of Commerce State Plan I.D.Number <br /> Sanitary Permit Application d <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,if 5.040)(m) Project Address(if different than mailing address) <br /> L Application Information-Please Print All Information C709-0 we leA <br /> Parcel k Lot k Block W <br /> Propcny Owner's Name <br /> Tarr peers 036 �1y3y- Q/ >06 <br /> Property Owner's Mailing Address Propeny Location <br /> /Od J 0,-0-4 5e /?�' 3E '/., Nom'/, S«tion 7✓f <br /> City,State Zip Code Phone Number <br /> ((cmeo e) <br /> OSG C064 WS S-✓�c/O 7✓.f J94`3369 T t/D Ni R /7 Eo� <br /> 11.Type of Building(check all that apply) Subdivision Name CSM Number <br /> 2(1 or 2 Family Dwelling-Number of Bedrooms 3 <br /> ❑Public/Commercial-Descnbc Use <br /> ❑City ❑Village Township of (An1eN <br /> ❑State Owned-Describe Use <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System rReplacmnent System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑Permit Renewal ❑ Permit Revision El Change of ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.T e of POWfS S stem: Check all that apply) sail ❑ At-Grade ❑ Single Pass Sand Fitter ElId Non-Pressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable <br /> Constructed Wetland 11 Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter El <br /> Recirculating Synthetic Media Filter ❑Leaching Chambtt ❑Dnp Line ❑Gravel-less Pipe ❑Othtt(explain) _ <br /> V.Dis ersaVTreatment Area Information: Elevation <br /> Design Flow(gpd) Design Soil Application Rate(gpdsQ Dispersal Area Required(sf) Dispersrsaal�ea Proposed(sf) System"?,AQ <br /> vs-o . 7 6vs <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 Tanks <br /> Septic or Holding Tank 4000 /000 <br /> Aerobic Treatment Unit <br /> Dosing Clamber bop bQQ <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> 2-11014� J`t 5-8 si 7iS- n 0- v/r> <br /> Plumber's Address(Street,City,State,Zip Code) <br /> .(7 7& 9w 3s Webs{r✓ w� SY1893 <br /> VIII.Coun /De artment Use Only <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuin gent gnaw o Stamps) <br /> Approved ❑ Disapproved Surcharge Fee) <br /> ❑ Owner Given Reason for Denial <br /> IR.Conditions of Approval/Reasons for Disapproval , <br /> Attach complete plan(to the County only)for the system oa paper not less than 81/2 x 11 inches io slu <br /> SBD-6398 (R. 01/03) <br />