Laserfiche WebLink
Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 (3u E n e1`1 <br /> isconsin Madison,WI 53707-7162 Sanita7�Permit Number(to be filled in by Co) <br /> Department of Commerce (608)266.3151 ff'7B�Z3 <br /> Sanitary Permit Application State Plan 1.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl 5.04(1)(m) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Information /t �j rt <br /> Property Owner's Name Ob b U,h f 31Y I Ye//®� �i✓c✓ �� <br /> n Parcel k Lot N 3 Block k <br /> ,Sco7f' /ye ra%r <br /> Property Owner's Mailing Address D ,1, °- 9/9-4-- Q 6 4 <br /> Property Location <br /> tid�H drew ,q✓e 5. <br /> City,State Zip Code Phone Number —Y., —%, Section <br /> M & (circle oyy��) u�-1 <br /> If.Type of Building(check all that apply) T y0 N; R /6 E orgy/ <br /> 1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name CSM Number <br /> ❑Public/Commereial-Describe Use �1 V-?/�i�0� <br /> 11 State Owned-Describe Use ❑City_❑Villagelad"rownshipof 19k/anpQ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ,'News stem <br /> Y ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B• ❑Permit Renewal ❑Permit Revision ❑Change of ❑Per Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration - Plumber Owner <br /> 1V.T e of POWTS S ICheck all that a I <br /> 0 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 Pi <br /> V.Dig ersal/I'reatment Area Information: Pe ❑Other(explain) <br /> Design Flow,g, Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> Z/so . S 90o Sao 93•V 9,2.ao <br /> V1.Tank no Capacity in Total Number ManufacNrer Prefab Site Steel Fiber <br /> Gallons Gallons of Units Plastic <br /> New Existing Concrete Constructed Glass <br /> Too" Tanks <br /> Septic or Holding Took �DOQ <br /> /ooD <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb <br /> /?/GZ/ MP/MPRs Number <br /> Business Phone Number <br /> IG HO kr.,s <br /> Plumber's Address( tree[,City,State,Zip Code) <br /> d776d f/.- 3s we6sh �vS 59893 <br /> VII .Count /De artment Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Iss ng A t Signatu o Stamps) <br /> N <br /> ❑ Surcharge Fee) 't' POwner Given Reason for Denial � r n <br /> IX.Conditions op,,rprovaURessons Tor Disapproval / <br /> � r�`' (V5',5V6&41 Xr4ef"Iams GA Q//ro✓d are -ehc o%/csE !r wr/46'e <br /> Frna, f�lc at£t.�l,a.( sof/ Rc�r6. <br /> Arpch complete Alam(to the County only)for the system on paper nor Ips than 812 x 11 inehp in size <br /> SBD-6398 (R. 01/03) <br />