Laserfiche WebLink
Safety and Buildings Viviston county <br /> 201 W. Washington Ave., P.O. Box 7162 <br /> NvieA,en t577- <br /> sconsin Madison, WI 53707-7162 Site Address <br /> Department of Commerce Aftmo 4m dtay?87 <br /> Sanitary Permit Application Sanitary Perr'm�/iit(}/umber <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide � ( � 7 <br /> C1 Check if Revision <br /> may be used for secondary purposes Privacy Law,s15. 1)(m) * 2-8 Q W <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> OZrr-9375- ,700 O� <br /> Property Owner's Name Parcel Number "- <br /> - ,Boa i He a ` L Dorn io � <br /> Property Owner's Mailing Address L Property Location <br /> .3x141 /LgAaE G. Sf 'A:S T O N.R 4 <br /> City,Sate Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Numix <br /> ./R++13�►' SyFi3o -3 S -e 4 y U <br /> II.Type of Buil g(check all that apply) ❑City <br /> or 2 Family Dwelling-Number of Bedrooms 3 ❑Village <br /> ❑Public/Commercial-Describe Use Township <br /> ❑State Owned Nca t Road <br /> r— <br /> Sedy►e / A01 1J <br /> III.Type of Permit: (Check only one box on line A(numbering scheme forinternal use). Complete line B if applicably!) <br /> ns <br /> New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> stem I Tank Only Existing System <br /> B. 1 ❑ 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 ItL;Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Weiland <br /> 22 11Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./inch) Elevation <br /> 5/50 4.15'0 !o 6,0 •-7 iw6e l 93.0 >9,5-4 <br /> VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Sic el Fiber Pb,:tic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or gni T+ttlt x ' <br /> O d <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the yiVersigned,2numA responsibility for installation of the POWTS shown on the attached ph ns. <br /> Plumbgf�nq�rE?a t y EXCAV Signature MP/MPRS Number Business Phon::Number <br /> N9112 �s77C�CfrO���tULV oNTMt G/L`INE OA QA9 f7 <br /> Plumber's"a7rVIlMi", Code) <br /> 715-635-7482 <br /> VIII. Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing n ignamre tan ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse �l ./7VIA 04 <br /> j <br /> Determination �/ � <br /> LX. Conditions of ApprovaLfReasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 8112 s 11 inches in she <br /> SBD-6398 (R. 05/01) <br />