Laserfiche WebLink
Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 te <br /> ` <br /> in Madison,WI 53707-7162 Sanitary P_ermit Number it be filled in by Co.) <br /> isconsin (608)266-3151 l�C % 7��— <br /> De artment of Commerce State plan I.D.Number <br /> Sanitary Permit Application 1.21?In accord with Comm 83.21,Wis.Adm.Code,personal information you provide pro ect Address(if different than mailing address) <br /> may be used for secondary purposes Privacy Law,sl5.04(1 xm) J <br /> L Application Information—Please Print All Information tL M�,L L <br /> Property Owner's Name �` P cel 8 IC Lot 4 Block a <br /> property Owne's Mallin dress Property tion <br /> -Pro _v, Sect on 1 3 <br /> City,State Zip Code Phone Number <br /> / S C� Z � (circle one) <br /> `A ✓ L T N; A r <br /> IL T&of Building(check all that apply) Subdivision Name CSM Number <br /> I or 2 Family Dwelling-Number of Bedrooms 2l CmG�C eP4 <br /> p,tifucommeroial-Describe Use <br /> ❑City �Viliage Township of-Serb TE <br /> ❑State Owned-Describe Use <br /> III.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A. ❑New System q Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification m Existing System <br /> List Previous Permit Number and Date Issued <br /> B. ❑permit Renewal ❑Permit Revision 11 Change of 13 Permit Transfer to New - <br /> Before Expiration Plumber Owner <br /> IV.T of POWTS S stem: Check all that a I <br /> ❑Non-Pressurized In-Ground ❑Mound>2A in.of suitable soil ❑ Mound<24 in.of suitable soil ❑At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Welland f L pressurized 1n-Ground ❑Holding Tank . ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> _ Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line U Gravel-less Pipe ❑Other(explain) <br /> V.Dia ersaVfreatment Area lnformation: C <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Required(sl) Dispersal Area Proposed sf) System Elevation <br /> 7..,> (O _ 7 1071-25 1 ) 08g. S I • 2 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab site Constructed Steel Fiber Glass Plastic <br /> Gallons Gallons of Units Concrete <br /> New Etdstivg <br /> Tetat�s,./� Took. <br /> Septic or Holding Ten: 2 ' <br /> Aerobic Treatment Unit <br /> Dosing chamber ,� — LA <br /> VII.Responsibility Statement-I,the undersigned,assume r mobility for installation of the POWTS shown on the attached plans. <br /> Plumber' ame(Print Plumber's Si m MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Li_� -�7 f QQ W . S /lh IlO ` yll <br /> VI .Coun /De artmcnt I a Onl <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuin [Signatu Stamps) <br /> Approved ❑Disapproved Surcharge Fee) C/, Y�y O� <br /> [IOwner Given Reason for Denial Ff O(tv 11 <br /> IX.Conditions of Approval/Ressom for Disapproval _ <br /> Anaeh tamplete plain(to We Comty only)for the system on paper not las Wen 812 z l l inches iu size <br /> SBD-6398 (R. 01/03) <br />