Laserfiche WebLink
OIN OOMPUT , t <br /> Safety an uildings Division County <br /> Ivisconsirn <br /> 201 W.Washington Ave.,P.O.Box 7162 Qc-_r PiG Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> (608)266-3151 �-,�,7Z z �j �J <br /> Department of Commerce 7� •C. <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide (((W <br /> may be used for secondary purposes Privacy Law,sI5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information—Please Print All Information <br /> o�� $ L _X Lk <br /> Property Owner's Name Parcel# Lot# Block# <br /> Chad R06ran 1'01 �-�-3°I'I(a ' Ia '34�-000' la <br /> Property Owner's Mailing Address Property Location <br /> / S�S o l d �h, _%4, Section <br /> City,State Zip Code Phone Number <br /> Go v COra n 1Y11V SS3y0 (ol —9(oS 7s3 j i-ircle one) <br /> T,_ __N; R_' E or® <br /> II.Type of Building(check all that apply) <br /> ®1 or 2 Family Dwelling—Number of Bedrooms <br /> 3 Subdivision Name CSM Number <br /> ❑Public/Commercial—Describe Use <br /> ❑State Owned—Describe Use ❑City_❑Village JgTownship of 07eerso h <br /> I11.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' .[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.Type of POWTS System: Check all that apply) <br /> XNon—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 /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Lf5"o . S 9160 CIN I 'F l-S` t 92. 0 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank /000 /00 0 <br /> Aerobic Treatment Unit <br /> Dosing Chamber 600 ,f 0 <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> /7tck f/apk,Mr /2-zl� f� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ok 7 76/0 Ht... 35-- WeCsf:°r l vL S4`�93 <br /> VI1I.Coun /De artment Use Only <br /> -/ Sanitary Permit Fee(includes Groundwater Date Issued Issuing en gnature tamps) <br /> Ip Approved ❑Disapproved Surcharge Fee) <br /> ❑Owner Given Reason for Denial ✓i/i ���� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />