Laserfiche WebLink
Safety and Buildings Division Coun <br /> `MA, 201 W.Washington Ave.,P.O.Box 7162 �je✓ry Lo)'{" <br /> isconsin Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 4 pJ)(4— <br /> State Plan I.D.Number <br /> Sanitary Permit Application <br /> is In accord with Comm 83.21,Wis.Adm.Code,personal information you provide O(� <br /> may be used for secondary purposes Privacy Law,s15.04(l$m) Project Address(if different than mailing address) - ) <br /> i <br /> 1. Application Information-Please Print All Information r� 303-7 <br /> ��PFQ✓ sky �✓I✓C <br /> Property Owner's Name Pates;p co r40 144t it Block is <br /> tJGrr r0. tS AU? 3994 Kal P. a/ Doe 379403 <br /> r's <br /> Property OwneMailing Address Property Location <br /> �7539 J eF�f�;�s RSP• Gov 4- Cqom 191-�. <br /> 1A '/., Section I\ <br /> I. City,State Zip Code Phone Number <br /> Wp�j-fy(r lfll S4l93 716-�G6- �f/3`/ (circle <br /> If.Type of Building(check all that apply) T N; RE <br /> r�l or Family Dwelling-Number of Bedrooms Subdivision Name /�11 CSM Number <br /> ElI pl .3 oia- � <br /> PubliGCommercial-Describe Use qaa8'- V.3--t� <br /> j ❑State Owned-Describe Use ❑City_❑Village',Township of�l <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System ❑ Replacement System ❑TreatmenVHolding Tank Replacement Only El Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of [o New <br /> List Previous Permit Number and Date Issued <br /> ❑Permit Transfer <br /> Before Expiration Plumber Owner <br /> i <br /> IV.Type of POWTS System: Check all that apply) <br /> Non-Pressurized In-Ground ❑ Mound?24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑At-Grade ❑Single Pass Sand Filter ❑ <br /> j <br /> Constructed Wetland 11 Pressurized In-Ground El Holding Tank ❑Pea[Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dis ersaVfreatment Arca Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(sf) System Elevation <br /> '/so . 7 (43 I C. y8 V•-TO 7�-, 0c) <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site teal Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank �OQO <br /> iaoo / sea X <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Rick Ae k,.+s �-� f/ dCfssri ��s_ 8as _ y/s-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 776 w I, 3S-- WGJ'JfE.- W.T S'r'Te9_7 <br /> VUL County/Department use <br /> Onl <br /> Approved ElDisapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing ent ignature mps) <br /> Surcharge Fee) <br />- ❑Owner Given Reason for Denial rK � P'p�y/ udd <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plain(to the County only)for the system on paper not less than 81/2 x 11 inches in sin <br /> SBD-6398 (R. 01/03) <br />