Laserfiche WebLink
• <br /> UN t;UMPIJTER/SCA{VNED <br /> Sanitary Permit Application Safety 8c Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application 15 Box 7302 <br /> 14sconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of commerce [privacy Law,s.15.04(1xm)] (Submit completed form to county if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Permi Number O Check if revision to previous application State Plan I.D.Number <br /> J,^tee 521 o 1557401 <br /> I.Application Information-Please Print all Information Ul& tir) 2. `' I Location: <br /> MwnerName Properly Location r-' r/!: WA 1145W 1/4,S 149 T,:j�),N,RSA(,,IA <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> H.Type of Building: (check one) E3 City <br /> )Or 1 or 2 Family Dwelling-No.of Bedrooms: -� ❑Village <br /> ❑Public/Commercial(describe use):_ Town of <br /> ❑State-Owned ,r/s <br /> NearestO� c J v <br /> 79 <br /> Parcel Tax Number(s)ez G-Z 5//9,-8%0 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. ,MReplacement 3. O Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> ❑Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground )aHolding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other. <br /> V.DispersaUTreatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 1 3.Dispersal Area 4.Soil Application 5.Percolation Rafe 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Galslday/sq.R) (MinJinch) Elevation <br /> VIL Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation oC4 POWTS shown on the attached plans. <br /> Plum Name Plum MP/MPRS No. Business Phone Number <br /> ;r <br /> ie�4 1 row <br /> P umber's Address Street,City,State,Zip <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin Signattm ps) <br /> U Approved ❑Owner Given Initial Adverse Surcharge Fee) ��(] - 9 5/ �� <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br />