Laserfiche WebLink
Safety and Buildings Utvtston Lou n. �,,,[ <br /> \\*vtisconsin <br /> 201 W. Washin ton Ave., P.O. Box 7162 1 /' //Madison, WI 53707-7162 Site Address /. <br /> Department of Commerce g ���� ALA."), <br /> Sanitary Permit Application Sanitary Permit Number <br /> 9. <br /> in accord with Comm 83.21.Wis.Adm.Code,personal information you provide ❑ Check if Revision G� C <br /> may be used for secondary purposes Privacy Law.s15.04(lxm) / +�J t <br /> I. Application Information-Please Print All Information (cf)._14.9se <br /> State Plan l.D.Number 9 <br /> Property Owner's Name Parcel Number <br /> ,, YeAr I-z Dfi} 2gv -e 3 Imo <br /> Property Owner's Mailing Address QQ Property Location <br /> a""1' G��/ R7 O� / I - T J? <br /> S N,RI S •I <br /> City,State _ Zip Number Lot Number Block Number <br /> %Av <br /> _ _rk.. /��/_ _ 6 5 //Q 9 7/5"-- Subdivision Name CSM Number <br /> 3A't9 $i50/ <br /> II.Type of Building(check all that apply) ❑City <br /> j1 or 2 Family Dwelling-Number of Bedrooms 3 ❑Village❑Public/Commercial-Describe Use 'Township h/ rh / 4 .` ` <br /> ❑State Owned Ne st Road � <br /> ineho /ti % <br /> III.Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> 1 0 New 2�Replacement System 3 0 Replacement of 6 ❑ Addition to For Count useA. System Tank Only I Existing System y <br /> B• ❑ Check if Sanitary Permit Previously Issued ( Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44,Non-Pressurized In-Ground 210 Mound 47 0 Sand Filter 50 0 Constructed Wetland <br /> 22 0 Pressurized In-Ground 41 0 Holding Tank 48 0 Single Pass 51 0 Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49 0 Recirculating 30❑Other <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(GaIs./Days/Sq.Ft.) (Min./Inch) .$7, EOvaron <br /> 147 ‘4A3, ' 7 <br /> �'9-` �113.‘P/ <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> c�,�- Holding Tank /r, <br /> ii -.r <br /> ` • r X 45e / /T/ , /c <br /> e- <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility f6 7 <br /> • •Illation of the POWTS shown on the attached plans. <br /> Plum s Name(Print) Plumber' Si ture 1 MP/MPRS Number Business Phone Number <br /> Mw ;r-I z- l i/i73 7/5' % 4 2q-3 <br /> Piu.•. is A ass(Street,City.State,Zip Code) <br /> 'IO /6e 9 4----Ge_ ‘ gfre efra 5-eise07/.._ _ <br /> VII Count /De•artment Use Onl Alli <br /> ki Approved 0 Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing� Sigtnture � <br /> Surcharge Fee) / <br /> 0 Owner Given Initial Adverse 50 r14 04 <br /> Determination �( <br /> IX. Conditions of ApprovaUReasons for Disapproval ( <br /> Attach complete plans(to the County only)for the system oo piper not less than 31(2 x 11 inches to star <br /> SBD-6398 (R. 05/01) <br />