Laserfiche WebLink
Sstctc and Bwldmg s Disision I count, <br /> L ivy. <br /> j 101 W. Washington,Ave..P O.Box'l6- Baru t?jrr <br /> Madison,Nil 53707-7162 Wisconsin Sanitary Pemnt Number(m be Glicd in b}Co <br /> Department of Commerce (608)266-3151 4 <br /> 72440 <br /> Sanitary Permit Application State Plan I D Number <br /> 6t accord with Comm 83.21,Wis.Adm.Code,personal infonnation you provide ,^1 <br /> may be used for secondary purposes Privacy Law,s15-04(I)(m) Proiect.Address(if different than mailing address) 0` <br /> I. Application Information-Please Print All Information W <br /> 7 7767 f,-ospcer-- <br /> Property Owner's Name Parcel# Lot# Block# <br /> iY7 i�,2 f a u.lsmn oa o q/8o o r3ot7 <br /> Property Owner's Mailing Address Property Location <br /> ' / 36�t0 Fo��sfvi>°Iv Ln <br /> City,State Zi Code Sw '/•, SW �4, Section �O <br /> Zip Phone Number <br /> .S'.r6L 7 7103-41611—/O// (circleo e) <br /> if.Type of Building(check all that apply) T y0 N; R Ab E or� <br /> &I or 2 Family Dwelling-Number of Bedrooms '� Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use V I I L5 <br /> 11State Owned-Describe Use []City_ Village PfTownship of 0#4kM P1a13rL_ <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> KNew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.T e of POWTS S stem: Check all that apply) <br /> — <br /> IXNon-Pressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in,of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter L <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.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 1S-o . S` _ 900 9Cb 173.7. <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber <br /> Gallons Gallons of Units Plastic <br /> Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank �d <br /> /000 <br /> Aerobic Treatment Urut tv <br /> Dosing Chamber <br /> 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> VII.Responsibility Statement- <br /> Plumber's Name(Print) Plumber's Signature MP/IvIPRS Number Business Phone Number <br /> ? X66-yrr7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> o17760 //tr 3s s✓ebs¢e._ k/-S% got-v3 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater I Date Issued Issuin ge Signatu o Stamps) <br /> Surcharge Fee) 4 ez-50 <br /> El Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> P45wE'0a1 'r 0.50 TnJFLTRftrvv'i)/ZAT16, 40CA-riaof Sa#1- A9to,f�n.V /l((w <br /> 64 <br /> Attach complete plans(to the county only)for the system on paper not less than 1/2x 11 inches just= <br /> SBD-6398 (R. 01/03) <br />