Laserfiche WebLink
Safety gSaf & uildin s Division <br /> Sanitary Permit Application <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> `VSconSin Madison,WI 53707-7302 <br /> Department of Commerce Personal information you provide may be used for secondary purposes <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned. <br /> Attach complete plans to the county copy only)for the system,on Daper not less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Permit Number ❑C ck if //vision previous application State Plan I.D.Number " <br /> I.Application Information-Please Print all Information Location: <br /> Pro Owner Name Property Location l/� <br /> rLg C /V 1/4 1/4 � T N,lit E or <br /> Pro rty Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or qM Number <br /> �rcA-) 7 2 '7( q—�4/7 <__-14 21, L <br /> II.Type of Building: (check one) ❑city <br /> PL i or 2 Family Dwelling-No.of Bedrooms. ❑Village <br /> ❑ Public/Commercial(describe use): .Town of <br /> ❑ State-Owned /)9'G GNG.� <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road r <br /> Tow Q� <br /> A) L ❑New System 2. placement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numbers)) 5'- <br /> /C <br /> stem TankOnl Existin S stem d�J 03 Y4406 <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previousl issued <br /> IV.Type of POWT System: (Check all that apply) <br /> j4Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> L Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> _ -300 �o 32 / 7 <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> 73d 75V ❑ ❑ ❑ ❑ <br /> '0 W414 s � ❑ ❑ ❑ ❑ <br /> VI .Resp nsibility Statement <br /> I,the undersigned,assume res o ibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(pri ) Plumber's Signature no stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip ode) <br /> VIII.County/Department Use Only <br /> ❑Owner Give Sanitary Permit FYe(Includes dlvater Da s� Issui g 4 ra ' atu s ps) <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee) Ff_! UndlZ <br /> Determination r <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />