Laserfiche WebLink
Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 t //t�e <br /> Visconsin Madison,W1 53707-7162 Sanitary Permit Number(to be filled in by Co,) <br /> De artment of Commerce (608)256-3151 g'6 393 1 ) <br /> Sanitary Permit Application State Plan I.D Number W <br /> In accord with Comm 83 21,Wis,Adm.Code,personal information you provide / 3 3 6 Z 0 <br /> may be used for secondary purposes Privacy Law,sl 5.04(1 xm) Project Address(if different than mailing address) 1 } <br /> I. Application Information-Please Print All Information /nn <br /> W# 3 <br /> Property Owner's NameV <br /> i4 Parcel# Lol# Block# <br /> S G e T f} / )/els - <br /> Prope wner'sng Address a -/ Property Location 0_ L 1073 <br /> ,2 -///7Maili �+/ G/� �U /a, '/4,, Section J <br /> City,State Zip Code Phone Number <br /> ''� JJ a.5-��e- q ,(cncleon <br /> II.Type of Building(check all thatapply) T 3/N; R/ E o(aV <br /> �or 2 Family Dwelling-Number of Bedrooms SuNtlfvhiaa-Aleme CSM Number <br /> ❑Public/Commercial-Describe Use 3 A� � <br /> El State Owned-Describe Use ❑City_❑ r,�m Village lownship a <br /> t-'ZO <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ANew System Replacement System ❑ IreahnenHulding Tank Replacement Only Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit'I'mrafer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: ,,c(C,�heck all that apply) <br /> ElP9,Non—Pressurized In-Ground Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Welland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filler ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> nDealn'rcatment Arca Information: <br /> d) Design Soil Application Rate(gpdsf) Dispersal Area Required(sl) Dispersal Area Proposed(sf) SystetfLElevati <br /> 0 <br /> Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> Ncsv Exustiny <br /> Tanks Tanks <br /> mde- Ob0 <br /> Aerobic Treatment Unit <br /> Dosing Chamber QO — <br /> VII.Responsibility Statement- 1,the undersigned,a surae responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(( tint) PII bf is Signature MP/MPRS Number Business Phone Number <br /> G+if}r�e A-4 /Se�in !�t/c•r� ZZ �� 9/ __7Y 7� '-tni <br /> Plumber' Address(Street,City,Slate,Zip Code) <br /> VIII.County/Department Use Only <br /> Approved El Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Signatur Stamps) <br /> Surcharge Fee) /O Q <br /> El Owner Owner Given Reason for Denial V <br /> IX,Conditions of Approval/Reasuns for Disapproval <br /> Attach comploo,plans(m the Caunty only)for the syslnn on paper nat less than 81/2 s I I inches in aiee <br /> SBD-6398 (R. 01/03) <br />