Laserfiche WebLink
Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O.Box 7162 <br /> 8V&sconsin Madison,WI 53707 -7162 Site Address <br /> De artment of Commerce <br /> Sanitary Permit Application Sarutary Permit Number <br /> �J <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision <br /> may be used for secondary purposes Privacy Law,sl5. 1 m <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> Property Owner's Name Parcel Number v of W <br /> Q bl 2-9aS0 - -3 600 <br /> Property Owner's Mailing Address Property Location <br /> / / ( yd �s- <br /> G� OlG/ /!Ii / �/ A / 'k S6;S T N, ER <br /> City,State Zip Code Phone Number Lot Num Block Number <br /> 7 Subdivision Name E£A4-18ambeF--" <br /> N � ,ocA �� ��GO 3yf-701P e,r rrL� I fdG%V <br /> H.Type of Building(check all that apply) ❑City <br /> �4or 2 Family Dwelling-Number of Bedrooms ❑Village <br /> ❑Public/Commercial-Describe Use kkownship S G/�_j <br /> ❑State Owned Nearest Road <br /> /__*/J t- Ae <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B If applicable) <br /> A For County use <br /> 1 -New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to <br /> S stem Tank Ord Exis' S stem <br /> B. El Check if Sanitary Permit Previously Issued <br /> Permit Number Date Issued <br /> TV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 77-Non-Pressurized In-Ground 2111 Mound <br /> 47❑ Sand Filter 50 11 Constructed Wetland <br /> 22❑ Pressurized 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 FloKd al Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> d Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> 0O � y3�VI.Tankpacity in Total Number Manufacturer PrefabSite Steel FiberPlastic <br /> allons Gallons of Tanks Concrete Constructed Glass <br /> Existing TanksSeptic or Ho - 60 J p r I J a- S L d <br /> Dosing Cha <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Pfj'°t) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,ZT Code) <br /> /L o?C -S—/fj/ S"/' e rJ v-Iat�- 6 <br /> Coun /De artment Use Onlyent Si mre o Stamps) <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuing Ag gun (N <br /> Approved ❑ Disapproved Surcharge Fee) �1 <br /> ❑ Owner Given Initial Adverse- � , 0U ' <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the Cowry only)for the system oa paper not less than$1/2 111 inches in she <br /> SBD-6398 (R. 05/01) <br />