Laserfiche WebLink
Safety and Buildings Division County <br /> ` 201 W. Washington Ave.,P.O. Box 7162 C/PA)�/ <br /> isconsin Madison, WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 LLQ <br /> Sanitary Permit Application State Plan I.D. Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15.04(])(m) Project Address(if different than mailing address) O <br /> 1. Application Information-Please Print All Information w,yeiltV LJ N'Vff fU <br /> Property Owner's Name ( Parcel X Lot M /a7 Block# <br /> K G f Oso-9l - - o0 <br /> Property Owner's Ma fling Address <br /> Property Location <br /> / 0 5 � _ /6 L) <br /> City,State Zip Code Phone Number 'A• 4,Section <br /> N�oe� e r /Yl .J sS3%� (circle ) <br /> 11. Type of Building(check all that apply) T YO N; R 6 E or ' <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use If/U e- t— Q A �',S <br /> ❑State Owned-Describe Use ❑City_❑Vglage whip f <br /> II$;(Checkmit: (Check only one box on tine A. Complete line B if applicable) K/ <br /> Astem ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification m Existing System <br /> Berewal ❑ Permit Revision ber and Date Issued <br /> iration IVWTS S stem: (Check all that a 1 ) <br /> d In-Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter <br /> ❑ Constructed Weiland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter <br /> ❑ Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe Other(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Y5-0 - - 6 `/3 G S—d ys <br /> VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or H <br /> Aerobic Treatment Unit <br /> Dining Clamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached pians. <br /> Plumber's Name(P 'n 0 Plumber's Signa turc MP/MPRS Number Business Phone Number <br /> v S�c�irr 22769/ 3yy- 7z�'G <br /> Plumbner's Address(Street , City,State,Zip Code) <br /> VIII. Count /De artment Use Onl <br /> Approved ❑ Disapproved Sur Permit Fee(includes Groundwater Date Issued Is gent Si (No Stamps) <br /> Surcharge Fee) �(' � (� 53ou <br /> ❑ Owner Given Reason for Denial ,Fr/ <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> Attach complete plass(W the Comfy only)for the sysnem on <br /> paper sot leu Was 81/2 s 11 Inches W size <br /> SBD-6398 (R. 01/03) <br />