Laserfiche WebLink
Safety and Buildings Division County !PW' <br /> 201 W. Washington Ave.,P.O. Box 7162 <br /> *SCOnSin <br /> Madison,Wl 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 5,519&5 <br /> Sanitary Permit Application�� sem" Number eo 0) <br /> In accord with Comm 83.21,Wis.Adm.Code, minrtmtimt Ovide U 1 <br /> may he used for secondary purposes Privacy Law,sIS.04(1)(m) Pmjm Address(ifdifferentmmiling address) <br /> I. Application Information-Please Print All Information ®��/fZrN (✓v�„/, <br /> Property Owner's Name Parcel# Lot# Block# <br /> C OZ8"/l/I0 l" 5 os_ap2 onma <br /> Property Owners Ma iling Address Property Location p <br /> 6 iyq ao!l NC5 (�(jv. L 1p 2 SectionA,Ylwt1 <br /> City,State //�� zip Code Phone <br /> Pbeme Number ?2� <br /> h��{f" ,/ '{2 L�Z���� 7 7v (circle ) <br /> T N; R / t E or4p <br /> II.type of Building(check all that apply) <br /> I or 2 Family Dwelling-Number of Bedroom Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑Village�6ownship of yt- <br /> III.Type of Permit: (Check only tate box on line A. Complete tine B if applicable) <br /> A, ❑ New System acemeta S <br /> ys �Repi ystem ❑ Tramem/Rotdmg Txdt Replacement only ❑ Other Mndifieation to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Charge of ❑Pe ntrit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWT3 S : (Check all that ) <br /> ('Non-Pressurized In-Ground ❑ Mound > 24 in.of suitable soil ❑ Mound < 24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter <br /> ❑ Constructed Weiland ❑ Pressurized in-Ground ❑ Holding Tarte ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirmlating Sand Filter <br /> ❑ Recirculating Synthetic Media Fiber ❑L=d ttg Chamber ❑Drip Line ❑Gravd-tens Pipe ❑odeer(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rategpdtf) D'¢persal Area Reeptted(sf) Diasal Area Pro <br /> l>aaed cap System <br /> 4 zElevation <br /> y0 <br /> VI.Tank Info Gpacity in Tont Nmobv Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank <br /> ff//WW �f <br /> Aerobic Treaurem Unit <br /> Dosing Chamba <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> M <br /> Name(Pain t) nae MP24PRS Number Business Phone Number <br /> Address(Street ,City,State, 7;= <br /> Code) <br /> 27ZZDA.1 o� <br /> VI .County/Department Use Ont <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing n ignamre( tamps) <br /> ❑ Owner Given Reason for Denial <br /> Suudnrge Fee) A;?r2 <br /> IX. Conditions of Approval/Reasotts for Disapproval <br /> Attarb complete plow(to the Coady emly)for the system em pope oat less that,612:11 inches in si e <br /> SBD-6398 (R. 01/03) <br />