Laserfiche WebLink
Safety and Buildings Division County Pp <br /> ` 201 W.Washington Ave.,P.O.Box 7162 prn'B 7/ <br /> ►scons�n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> (608)266-3151 <br /> Department of Commerce <br /> State Ian I.D.Number <br /> Sanitary Permit Application <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl 5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Informstion-Please Print All Information 3J�� Mw.;l <br /> Property Owner's Name / Parcel# Lot# 60Block# <br /> Jahn R/slf.tve <br /> Property Owner's MailinggAddress Property Location <br /> ^/'r L@MOLAR �B <br /> City,State Zip Code Phone Number -Al Section <br /> O WAIt@nn.L m X/ SSO60 X-07-390•/ /4 circle one) <br /> 11.Type of Building(check all that apply) T HO E o& <br /> Subdivision Name CSM Number <br /> I ort Family Dwelling-Number of Bedrooms /� f./,�{�q�� , /I / <br /> ❑Public/Commercial-Describe Use � ' Ir--Gti a �/ {/ <br /> El State Owned-Describe Use ❑City_❑village Township ofQ1 <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New S stem <br /> y 11 Replacement System ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of PO S stem: Check all that apply) <br /> QrNon-Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil ❑At-Grade ❑Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑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.Dis ersal/rreaIt I Area Information: <br /> Design Flow qn ) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 . 7 Yot9 "_r d.( 1 9,1. .1 <br /> VL Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New TExi ng <br /> Tanks Tanks <br /> Septic or Holding Teok �.9 8O0 <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's SignatureMP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> J 77(,o /4/t. .7s-- uJA6,6�rr L/l S'�893 <br /> =E1 <br /> Courtnt Use n.1 <br /> - <br /> Approvedroved Sanitary Permit Fee includes Groundwater Date Issued IssuingRAgent Signature(No Stamps) <br /> Surcharge Fee) (��a �r-� /C,�/ "� <br /> Given Reason for Denial (- c J l➢r0 r <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Anmh complete plans in,the County only)for the system on paper not less than$112 x 11 inch"in rim <br /> SBD-6398 (R. 01/03) <br />