Laserfiche WebLink
Safety and 13utldtngs uiviston county -,�}- <br /> 201 W. Washington Ave.,P.O. Box 7162 �ylvlo e'// <br /> `wisconsin Madison,WI 53707-7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondarypurposes PrivacyLaw,s15. lxm ❑ Check if Revision 7.z o1 <br /> I. Application Information-Please Print All Inf at n � 73 State Plan I.D.Number "� <br /> Property wner's Name Parcel Number <br /> :QJoi-'1rj 0 3 3-D4-(Q co <br /> Property Owner's Mailing Address Property Location a/--` <br /> J 6 J`'i 14110 -e_ J 'A5'tfu:S33T-37N.R E <br /> City,State Zip Code Phone Number Lot Number Bieck'J,,mber <br /> Subdivision Name CSM Numtx <br /> II.Type of Building(ch ck all that apply) OCity _ <br /> IS4or 2 Family Dwelling-Number of Bedrooms ❑Village / _/ <br /> O Public/Commercial-Describe Use OThwnship lift i alt,^514 /�-Irj <br /> ❑State Owned Nearest Road <br /> 7:--Z"r <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B i ) <br /> applicabic <br /> A. 1)L?I w 2 O Replacement System 3 ❑ Replacement of 6 ❑ Addition to For Cotsnty nue <br /> system I Tank Ordy Existing S stem <br /> B. ❑ Check if Sanitary Permit Previously issued Permit Number 7Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 -pion-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Weiland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unlit 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 Rate(Gals./Days/Sq.Ft.) (Min./lnch) Elevation <br /> y7, z <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Sieel Fiber Pb,;tic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New I Existing <br /> Tanks Tanks <br /> Septic or%leldinll-TAOk. d pO <br /> Dosm&Chamber <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility far installation of the POWTS shown on the attached plcems. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS NumberBusiness Phon-Number <br /> GJ4�i ,I?,/ '�'r, , tdcL<.la. Z �769/ �Y9- 7.�8'� <br /> Plum is Address(Street,City,State,Zip Code) 10.1 <br /> VIII. Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing em gnamre Staii ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse n �Qa 16.I r <br /> Determination �t <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plats(to the County only)for the system on paper not less then 8112 s 11 inches to size <br /> SBD-6398 (R. 05/01) <br />