Laserfiche WebLink
Safety and Buildings Division County ,ems <br /> NVisconsin <br /> 201 W.Washington Ave.,P.O.Box 7162 � ✓n e Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> (608)266-3151 <br /> Department of Commerce <br /> Sanitary Permit Application State Plan I.D.Number C1 ` <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 5.J <br /> may be used for secondary purposes Privacy Law,sl5,04(1)(m) Project Address(if different than mailing address) �Q <br /> 1. Application Information-Please Print All Information Gtr r('1`� Lin <br /> Property Owner's Name Parcel# Lot# Block# <br /> 1?ock- baa OS- I-aOD <br /> Property Owner's Mailing Address Property Location <br /> /863 Feed e en Gt <br /> NC h, A)L;" %<, Section d14 <br /> City,State�j Zip Code Phone Number <br /> NCW 8rt Oon W4 SS"//I� bSl- (oj3-�f�O b+"ircl <br /> T 4 i N; R_Etorr(J'& <br /> 11.Type of Building(check all that apply) <br /> a, Subdivision Name CSM Number <br /> 1 or 2 Family Dwelling-Number of Bedrooms D-_ <br /> ^� (/n� �/}ry <br /> ❑Public/Commercial-Describe Use ""' � v r 1 //6- <br /> ,�--es <br /> ❑State Owned-Describe Use ❑City ❑Village XrTownship of,Sw i 3 S W. <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> .Q New System El Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ 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 POWTS System: Check all that apply) <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 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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> 360 7 v e9 4_�3d- W. <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New7 Existing <br /> Tanks I Tanks <br /> Septic or Holding Tank 8oD goo <br /> w <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 Signature MP/MPRS Number Business Phone Number <br /> 141e�AJE , A6,­i406i!� 11 % -71r-�6�- <br /> Plumber's Address(Street,City,State,Zip ode) <br /> 7 760 w 3V_ k),e6s f{✓ k?/y ..5 V S ,? <br /> . <br /> County/Department Use Only <br /> ?,Approved Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuinnnggg Agent Signature(No Stamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> UC a� �7 ` <br /> n <br /> OCT 1 3 2003 <br /> 'lI <br /> Attach complete plans(to the Countys o 1 s han 87/2 x flinches in sin <br /> ZONING <br /> SBD-6398 (R. 01/03) <br />