Laserfiche WebLink
6YLL <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> con5inSee reverse side for instructions for completing this application PO Box 7302 <br /> 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 the system,on paper not less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Permit Number ❑ eckif vision to prevt us application State Plan I.D.Number <br /> U ti.✓£� o C <br /> I.Application Information-Please Print all Information L Location: <br /> Property <br /> lOwner Name /� Property Location <br /> /v,� C /1 `�J� JCl/43-,f1/4,S3J—T3-7,N,R/f(or)W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> SCity2_ 0_5- <br /> City, <br /> ,State Zip Code Phone Number Subdivision Name or CSM Number <br /> f�c�fc,'c lN= y23`7 ( 7/> >3Z7-81,53 <br /> Type of Building: (check one) / ❑City <br /> A <br /> 1 or 2 Family Dwelling-No.of Bedrooms: T ❑Village <br /> ❑Public/Commercial(describe use):_ M Town of <br /> 13 State-Owned <br /> Nearest Road <br /> Parcel Tax Numbe S a 0 0 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. kReplacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued / <br /> )�A Sanitary Permit was previously issued G 907— 7- 2-to- 7 Y <br /> IV.Type of POWT System: (Check all that apply) <br /> jeNon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-grountT,'7� fCaf ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(GalsJday/sq.R.) (Min./inch) Elevation <br /> G06 3-0 p 5/ </ 1 ?2 - 3 �?S- a <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> load / ❑ ❑ ❑ ❑ ❑ <br /> Z-0 <br /> 1:10 11 <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on hed plans. <br /> mber's Name(print) Plumber's Signature(no stamps): MTP No. Business Phone Number <br /> /�/ rs JQ 87 L '172 -,F VV(o <br /> Ptumber's Address(Street,City,State,Zip C ) <br /> i(.1D a6') th (2L)1 041/-u�% Sy55 3 <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee Includes Ground ater Date SmK Issuing Agent ignat re o s <br /> bXPproved ❑Owner Given Initial Adverse Surcharge Fee) O, Cr / µ,_ <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: VY _d <br /> MAY ZWI <br /> BUR�VCT r COUNTY` 1U 7d J— P�ti . v�/ � <br /> ZO <br /> SBD-6398(R.07/00) <br />