Laserfiche WebLink
Safety and Buildings Division County tN=ba <br /> P <br /> 201 W. Washington Ave., P.O. Box 7162 ig <br /> isconsin Madison, WI 53707-7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit <br /> Sanitary Permit Application <br /> In accord with Comm 83.21,W is.Adm.Code,personal information you provide �� <br /> be used for seen s Privacy Law, 5. 1)(m ❑ Check if Revision <br /> ma <br /> I. Application information-Please Print All Information _ Snre Plan I.D.Number <br /> Property,ow s Name Parcel Number l o - <br /> Property Owneris Mailing Address - �P(rfooppreertrty Location <br /> �L/ 1 C' Lines D - [VL— tAS 'A:S T dN.RJ7 <br /> City,Stare �• tip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> II.Type of Building(check all that apply) �7 ❑City <br /> 1 or 2 Family Dwelling-Number of Bedrooms J <br /> ❑Village <br /> ❑Public/Commercial-Describe Use ownship yt,J _ <br /> ❑Sate Owned Nearest Road <br /> oct 47 �Dd <br /> III.Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if pplicable) <br /> A. t ❑ New 1 „ Y Replacement System 3 ❑ Replacement of 6 ❑ Auaty me <br /> system Tank OnlyEzistin S stem <br /> B. ❑ Check if Sanitary Permit Previously Issued Pemut Number Date Issued <br /> IV.Type of Permit: (Check all that agp�plly)(numbering scheme is for internal use) <br /> 44�Non-Pressurized In-Ground 2VMound 47❑ Sand Filter 50❑ Constructed Welland <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 ersal/Treatment 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) Elevation <br /> naso 10413 zl�p9y <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks ConcreteConstructed Glass <br /> New Exiting <br /> Tanks Tanks <br /> Septic or Holding Tank0 - DG+v <br /> Dosing Chamber / <br /> ICSO <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility,for installation of the POWTS shown on the attached plans. <br /> Plumber's Name rant) Plumber's Sigre MP RS umber Business Phone Number <br /> r � ?SO 3/ <br /> Plumber's Address(Street,City,Sate,Zip Code) <br /> l� /9 Coles cv r <br /> VII Count /De artment Use Only <br /> Approved7Dettratination <br /> Disapproved Sanitary Permit Fee(includes Groudwater Date Issued Issuing at nature( mps) <br /> Surcharge Fee) <br /> Owner Given Initial Adverse 3UU aD <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not las than 81/2 x 11 inches Issue <br /> SBD-6398 T, 05/01) <br />