Laserfiche WebLink
151 Safety and Buildings Division Cou <br /> V <br /> m 201 W. Washington Ave., P.O. Box 7162 <br /> sconsin Madison,WI 53707-7162 Sile Address nn <br /> Department of Commerce w66sR KD <br /> Sanitary Permit Application Samrary Pemut Nsunber <br /> In accord with Comm 83.21,Wis.Adm.Code.personal information you provide 4951427ma ^w <br /> be used for seen s Privacy Law,sl5. IXm ❑ Check if Revision CJ <br /> I. Application Information-Please Print All Information Snrc Plan LD.Number <br /> Property Owner's Name Parcel Number <br /> Property Owner's ailing Address -PA <br /> Pr©'a_ `�D� ` O l — �bo <br /> C 1 _ p petty lavation 12,00 107 9 <br /> S T <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> 1 5 a Subdivision Name CSM Number <br /> 2 v TT MtV J <br /> 9S3 - Sq c o <br /> U.Type of Building(check all that apply) Dory <br /> 6&1 or 2 Family Dwelling-Number of Bedrooms <br /> ❑V81age <br /> ❑Public/Commercial-Describe Use nshi f11 <br /> ❑State Owned Nearest Road <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A' 1 New 2 ❑ Replacement System 3 11Replacement of 6 11Addition m For County weS stem Tank Only Existin S stem <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 A Non-Pressurized In-Ground 21❑ Mound 47❑ Sand Filter 50❑ Constructed Weiland <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.Dis ersaUTreatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) fZ f r <br /> Up� 9J �� Elevation <br /> Oso 3 t`? ; 94.Z 92�' c� <br /> VI.Tank Info Capacity in i Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Commit Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank <br /> e of <br /> Dosing Chamber <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) PIT <br /> her's Sig r MP/MPRS Number Business Phone Number <br /> L)5 t)10 l�psn d -71 — <br /> Plumbcr's Address(5 et,City,Sum.Zip Code) <br /> \VgFS0a_1:)3M o <br /> VIII. Count /De artment Use Onl <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Dare Issued Issuing a Sigmmre amps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse <br /> Demrmirsation �1 <br /> IX. Conditions of ApprovaltReasons for Disapproval <br /> ��isr/A� CsA2kGE b <br /> 96 A--V&)0 bine T 1A)5&,tfA6,., of s,r 2��t bH c rf <br /> Attach complete plans(to the County only)for the system on paper not less than 9112 x 11 laches in sine <br /> SBD-6398 (R. 05/01) <br />