Laserfiche WebLink
Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> iseonsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [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 Om system,on paper rQt less than 8-1/2 x I 1 inches in size. <br /> Couru Stets P Sanitary O if 81 to previous lication State Plan I.D.N <br /> /'nJ 0�1 <br /> I.Application Information-P se Print alrbilldrnfatfou Location: I /� <br /> Property Owner Name L Property Location <br /> ^j //e r 1/4 1/4 S3 t/d N R/Q or <br /> Property Owner's Mailing Address <br /> Lot Number Block Number <br /> p IlAcle S, <br /> city,StateZip Code Phone Number Subdivision Name or CSM Number <br /> ep�liJ a� itJ� S <br /> Type of Building: (check one) 0 City <br /> 1 or 2 Family Dwelling-No.of Bedrooms. ❑Village <br /> ❑ Public/Commercial(describe use): Town of / <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> C e <br /> A) I. ew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) _ _ <br /> System Tank Ortl ExistingSystem 6 e3 <br /> B) Permit Number Date Issued <br /> ❑A Sari Permit was reviousl 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 ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dis ersaVTreatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Ates 3.Dispersal Arca 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Galslday/sq.fl.) (Min./inch) Elevation <br /> ys0 Ys0 /. c . 6 <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete strutted <br /> Tanks Tanks <br /> / ❑ <br /> /OOr7 ❑ ❑ ❑ <br /> _j ,P 7`i c OoIJ <br /> ❑ ❑ ❑ ❑ <br /> o� <br /> V11.Responsibility Statement <br /> I the undersigned,assume MM2!jstbi1ity for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature( stamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Ipcludes Grount^ ttteer Date Iss / Issuing <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee) , L �Or�/ �� Z-, / <br /> Determination �C /� <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 807/00 <br />