Laserfiche WebLink
(-' A Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O. Box 7162 Q <br /> Wisconsin Madison,WI 53707-7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application San azy Permit4 'II <br /> CN <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide k `s(OSP,R <br /> ma be used for sero s Priv Law,s15. t m 11 Check if Revision � � <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> 946'&&6e <br /> Property Owner's Name i Parcel Number <br /> I)AVICMV ) Geo- o -o —rfa DO <br /> PropertyOwner's �1 Address Property Location d (),) <br /> 345 'A ''A:S J r TO N,R E <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> W>~BST {t W SA �3 �(S W.- 4 S4V Subdivision84 V.7 CSM Number <br /> 1 - <br /> II.Type of Building(check all that apply) ❑City <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms ❑village <br /> Public/Commercial-Describe Use �'l. 7z 5 1T'eS owmhip 0AKj-99,0 <br /> ❑State Owned Nearest Road <br /> �- LLDtj IV15e RDa <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B applicable) <br /> A' 1 New 2 ❑ Repbs emem System 1 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> S stem Tank Od Existin S stem <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> I� <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44N�Non-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Constructed Wetland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rale System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> .S4O 772 1-7d- -7 <br /> VI. <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber plastic <br /> Gallons Gallon of Tanks Concrete Constructed Glass <br /> New Exiatiaa <br /> Tanks Tanks n <br /> Septic or Holding Tank I2� � ?=�o 1 �iaNl x <br /> owing Chamber <br /> VII.gespunjabinty Statement- I,the urrderadgaed,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 /> &-rev Ws z2sSs 715- S&6- 4157 <br /> lumber's Address(Street.City,State,Zip Code) <br /> 277 (oo 4W £8 • -54-513 <br /> VDI. Com /De s rtment Use Ofil <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date IssuedIssuing on sure tamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adversesif <br /> /t3 <br /> DeterminationT V - <br /> IX.Conditions of ApprovalMeasons for Disapproval /w y r <br /> Attach complete plena(to the Couuq only)for the ryrtem on?aper not Ins then 81/2.c 11 inches In size 0 v / <br /> SBD-6398 (R. 05101) <br />