Laserfiche WebLink
jqs 4 3vSa6 c�YV-1'PbP <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> Visconsin <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned. <br /> Attach complete plans to the county copy only)for the system,on papek not less than 8-1/2 x 11 inches in size. <br /> Count State anitary Pe it Number ❑C ck if revision6to previo application State Plan 1.D.Number <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> S0SE91+ 1/4 1/4 S T N, or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 157 SummiT AV- 747- <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> ST-PAUL Nt 1J- SS"/OS COSI 2011- &/-IrJZS SU60- <br /> Il.Type of Building: (check one) ❑city <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑ Public/Commercial(describe use): Mown of <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road&LSQ4 <br /> A) I. ❑New System 2. X.Replacemcnt 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Only Existing S stem I — <br /> B) <br /> El Permit Number Date Issued <br /> A Sanitary Permit was previously issued <br /> V.Type of POWT System:(Check all that apply) <br /> on-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> RequiredProposedPropos/erdy., Rate(Gals./day/sq.ft.) (Min./inch) �] Elevation <br /> 4459 1�V W i S �� / 17. 1 <br /> VI.Tank Capacity in Total #of Manufacturer TO <br /> Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- glass <br /> New Existing structed <br /> Tanks Tanks Q q� 1 <br /> �O� I �R'�1 r/ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature o s ps): MP/MPRS No. Business Phone Number <br /> T� R>qn 1�ovw�ls zzS�ds� 7tg- 866- 4(-51 <br /> Plumber's Address(Street,City,State,Zip de) <br /> Z..'77 b o A= 3S LJ4ssr<a tJ I - 54893 <br /> VIII.County/Department Use my <br /> ❑Disapproved Sanitary Permit Fee(Includes GroundwaterT)W2�3-� <br /> Date Issued - Issuing A t Si mps) <br /> (� pproved ❑Owner Given Initial Adverse Surcharge! <br /> 7�00 <br /> Determination —�Y <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />