Laserfiche WebLink
i <br />SBD -6398 (R. 01/03) <br />Attach complete plans <br />only) for the system on paper not less than 8112 s 11 Inches In size <br />Safety and Buildings Division <br />201 W. Washington Ave., P.O. Box 7162 <br />County n <br />NVisconsin <br />•JL\/ e <br />Madison, WI 53707-7162 <br />Sanitary Permit Number (to be filled in by Co.) <br />Department of Commerce <br />(608) 266-3151 <br />, / 7 2 2 6a <br />Sanitary Permit Application <br />State Plan I.D. Number <br />In accord with Comm 83.21, Wis. Adm. Code, personal information you provide <br />may be used for secondary purposes Privacy Law, s15.04(1 )(in) <br />Project Address (if different than mailing address) <br />1. Application Information - Please Print All Information <br />Property Owner's Name <br />Parcel # Lot # Block # <br />Property Own is Mailing Address <br />Property Location <br />7 "Lell <br />I ,r e r l ' <br />��'r '/.�� '/., Section <br />City, State <br />Number <br />' , t <br />�Zi^plC�ode <br />J f . ` ,� <br />TPhone <br />�/ <br />1 y �-� i <br />� �J� circle ) <br />i �' N; RLTE oUW <br />I1. Type of Building (check all that apply) <br />I or 2 Family Dwelling - Number of Bedrooms <br />Subdivision Name CSM Number <br />Public/Commercial - Describe Use <br />State Owned - Describe Use <br />❑City_❑villagc xTownship of o p') `f S <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />X New S stem <br />y <br />❑ Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />C1 Other Modification to Existing System <br />B. <br />n Permit Renewal <br />❑ Permit Revision <br />❑ Change of <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Bcfore Expiration <br />Plumber <br />Owner <br />IV. Type of POWTS S stem: Check all that apply) <br />Non -Pressurized In -Ground ❑ Mound > 24 in. of suitable soil ❑ 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 ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) <br />V. Dispersal/Treatment Area Information: <br />Desiin Flow (gpd) Design Soil Application Rate(gpdso Dispersal Area Required (so Dispersal Area Proposal (st) System Elevation <br />` <br />V1• Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br />Gallons Gallons of Units <br />Concrete Constructed Glass <br />New Existing <br />Tanks Tanks <br />Septic Holding Tank{' <br />Acroblc Treatment Unit <br />Dosing Chamber <br />H71. Responsibility Statement- 1, the uilidersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's !Jame (Print) PI Ituber's Sign tore MP/MPRS Ntunber Business Phone Number <br />� <br />� G <br />Plumber's Address (Street. City, State, Zip Cpde) <br />��u lY _h(14e/", �� 3 <br />1('11 <br />ill. Countv/De artment Use Onl <br />Approved <br />❑ Disapproved <br />Sanitary Permit Fee (includes Groundwater Date I ued <br />Issui t Sign o Stamps) <br />❑ Owner Given Reason for Denial <br />Surcharge Fee) <br />C/ <br />IN (nn ditinne <br />of A..... ., I/De _ 9.._ nr______ <br />SBD -6398 (R. 01/03) <br />Attach complete plans <br />only) for the system on paper not less than 8112 s 11 Inches In size <br />