Laserfiche WebLink
L'cw G0, <br /> Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> `�sconsin See reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for seconds Madison,WI 53707-7302 <br /> Department of Commerce Y P Y secondary purposes <br /> [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 paper not less than 8-1/2 x 11 inches in size. <br /> State Sanitary Permit Nu ❑Check if revision <br /> to previous application State Plan I.D.Number <br /> I.A lication Information-Please Print all Informatitin Location: <br /> Property Owner Name Property Location ty <br /> ALD P APj)ud 1/4 1/4,SZT41 ,N,FgE(oonW J <br /> Property Owner's Mailing Address Lot Number <br /> 0245- IEUO-r 3bt+14'<X*1 12D_ L. Z <br /> City,State I Zip Code Phone Number Subdivision Name or CSM Number <br /> 'PAW_ aq 01 - S4830 <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑ Public/Commercial(describe use): Town of $G>15 S <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> 1Uor r7 <br /> A) 1. ❑New System 2. AfReplacement 1 3. ❑Replacement of 4. ❑Addition to Parcel Tax um b s) / O <br /> System Tank Onl Existing System (� <br /> B) Permit Number Date Issued <br /> ❑A SanitaryPermit waspreviouslyissued <br /> li <br /> IV.Type of POWT System: (Check all that apply) <br /> Non-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 Application5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 497 <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <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 SignaMP/MPRS No. Business Phone Number <br /> ci�X�Kq 4P/</A/5 w ture nos ps): ; 2S8_571 <br /> lumber's Address(Street,City,State,Zip C de) <br /> z7-760 35 I.IFSrz W S 893 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Is n Agent Signatu (No stamps) <br /> Approved 1 ❑Owner Given Initial Adverse Surcharge Pees) r <br /> Determination )p '(p <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />