Laserfiche WebLink
ON COMPUTER/SCANNED <br /> ` Safety and Buildings Division County <br /> AV IN 201 W.Washington Ave.,P.O.Box 7162 i' , t,. rc <br /> i!!S?fnsin Madison,WI 53707-7162 i Sanitary permit Number(to be filled in by Co.) <br /> DepaCommerce (608)266-3151 43 5 )1 r -1 <br /> Sanitary Permit Application State Plan I.D.Number/ <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide Q 7,"F <br /> may be used for secondary purposes Privacy Law,s I5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Infor7nbunh <br /> �-� laa�� SqN�' 1Q� <br /> Property Owner's Name p Parcel# pLot# Block# <br /> )fo-rintr Ork--C, <br /> Property Owner's Mailing Address Property Location <br /> City,State �Zi✓7 : p Code Phone Number - G Y'>L W Y'• Section c� k <br /> II.Type of Building(check all that apply) T�N; R�E org �✓ <br /> W I or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City ❑Village%Township of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) _ _ J <br /> A. - too <br /> New 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 70fPOWTS S stem: Check all that a l❑Non- ed In-Ground ❑ Mound>24 in.of suitable soil Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand FilterConstructnd ❑ Pressurized In-Ground ❑Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑Recirculathetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe p ❑Other(explain) <br /> V.Dispersal/Tr ersaVl reatment Area Information: h rG l C'- <br /> Desi Flow(gpd) Design Soil Application Rate(gpdsfJ Dispersal Area I equ�(s^ Dispersal Area Pro ssed(s ystem levation <br /> ;Amobic <br /> nk Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber <br /> Gallons Gallons of Units Plastic— <br /> Gallons <br /> Now Existing Concrete Constructed Glass <br /> Tanks Tanks <br /> r Holding Tank (' <br /> QU a) 4 <br /> Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume r sponsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum e41,gnat' ���W/MPRS Number/)/J�� / Business Phone Number <br /> eykzZ, , 1 1 07 2-L <br /> Plumber's dress(Street City,State, ip Code) <br /> u ( t S� <br /> VI Coun /De artment Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing en tgna tamps) <br /> Surcharge Fee) <br /> ❑Owner Given Reason for Denial �7 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not leas than 81l1 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />