Laserfiche WebLink
-Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> `�sconsin Personal information you provide may be used for secondary purposes Madison,Wl 53707-7302 <br /> Department of Commerce [Privacy Law,s. 15.04(1 xm)] (Submit completed form to county if not <br /> state owned <br /> ------------ <br /> Attach complete plans to the county copy only)for the s tem,on paper not less than 8-1/2 x I 1 inches in size. <br /> KWh State Sani t ylnber heck if reuion�o reg% application State Plan 1.D.Number <br /> ur .3 137, ter— L <br /> L A lication Information-Please Print all Information VLocation: <br /> Property owner Name _ Property Location <br /> A1Wl/4.St'✓1/4,S,&vT31,N R/ <br /> prop^^erty�owner's Mailing AddressLot Number Block Number <br /> City,State Lip Code Phone Number Subdivision Name or CSM Number <br /> II yof Building: (check one) LJ City—pe <br /> ❑Village <br /> A 1 or 2 Family Dwelling-No.of Bedrooms: WTown of <br /> O Public/Commercial(describe use): R J S K <br /> O State-owned <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road - �cd <br /> Rou,v �� <br /> A) 1, ew System 2. ❑ Replacement 1 3. ❑ Replacement of 4. ❑Addition to Parcel Tax Numbers _ <br /> Svstem Tank Only Existing System <br /> B) Permit Number oay- ala Dgeau^ed/� <br /> ❑A Sanitary Permit was previousiv issued <br /> I <br /> IV.Type of POWT System: (Check all that apply) <br /> A!! Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetiand <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other. <br /> V Dis ersaVrmatment Area Information: <br /> 1.Design Flow(gpd) 2.DispersalArea 3.Dispersal Arca 4.Soil Applica[ion 5.Percolation Rate 6.System Elev 7.Final Grade <br /> Required Proposed Rate(GaisJdayisq.R) (Minlnch) Elevation <br /> SSD 37S` 37 '? , 7 /• �L i — 93 - S.s /0 C) <br /> VI Tank Capacity in Total #of Manufacturer Prefab Site Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crcte strutted <br /> Tanks I Tanks <br /> / 000 <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII Responsibility Statement <br /> We undersigned,assume onsibili o t a' f OWTS shown on the attached plans. <br /> Plumber's Name(print) P m i o ps): MP/MPRS No. Business Phone Number <br /> John Solofra I #223779 715-376-2278 <br /> Pltmtbees Address(Street,City,Stare,Zip Code) <br /> PO Box 161; Gordon, WI 54838 <br /> VIII County/Department Use Only <br /> ❑Disapproved Sanitary Fee(includes Ground Date ued Issuing Ag t Si Ps) <br /> 4pproved [3Owner Given Initial Adverse S:!f ��,00 3�2/�Q 1- <br /> Determination // <br /> DL Conditions of Approval/Reasons for Disapproves <br /> i <br /> MAR 2 0 2002 <br /> BIERNE <br /> ZONING <br />