Laserfiche WebLink
Safety and Buildings Division County <br /> `�SCOnSin 201 W. Washington Ave., P.O. Box 7162 /3t'ess <br /> Madison, WI 53707 -7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary Permit Number C( pp !� <br /> In accord with Comm 83.21,Wis. Adm. Code,personal information you provide ❑ Check if Revision Ju /35 <br /> may be used for second purposes Privac Law,sl5. 1 (m) _ <br /> I. Application Information-Please Print All InformationZ9 State Plan I.D. Number <br /> Property Owner's Name Parcel Numbers � <br /> X40n GK4 /iwr drr 0 69-01- �7rIJ <br /> -dC� <br /> Property Owner's Mailing Address Property Location ` <br /> 79' Q9 134iley De. NW 'A AI W •s:S 30 T 40 N,R17 Hyl) <br /> City,State Zip Code Phone Number Lot Nylmber Block Number <br /> Subdivision Name .��,, CSM Number <br /> Eden PriArie WIN SS3Y7 9Sd- 9711- ifd-71 �" ILNS�TI6Cy <br /> n.Type of Building(check all that apply) ocity <br /> 0 1 or 2 Family Dwelling-Number of Bedrooms 3 ❑Village <br /> ❑ Public/Commercial-Describe Use ®Township kti ldirt <br /> ❑State Owned Nearest Road <br /> #1 hlued V. <br /> In.Type of Permit: (Check only one box online A (numbering scheme for internal use). Complete line B if applicable) <br /> A. 1 !New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> S stem Tank OnlyExistingSystem <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of Permit- (Check all that apply)(numbering scheme is for internal use) <br /> 44 K Non-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Constructed Weiland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 5l ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Raw(Gals./Days/Sq.F[.) (Min./Inch) Elevation <br /> LISO 6q3 104f . -7 '73. 9, 97. 0 <br /> VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank /000 /0 as <br /> Dosing Chamber <br /> VIL Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Priv[) Plumber's Signature MP/MPRS Number Business Phone Number <br /> c{{f}o2D �r/S 2 wk 2258 S I 715- Sw 4157 <br /> Plumber's Address(Street,City,State,Zip'Code) <br /> 27'1 (00 f w 35 u6osrm W I , 1�4g 3 <br /> VII . Count /De artment Use 1 <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing ABegt Signature( tamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse <br /> Determination •C✓ U <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the syneen on paper tut Ins than 8112 x 11 Inches,in size <br /> SBD-6398 (R. 05101) <br />