Laserfiche WebLink
Safety and Buildings Division County <br /> �� 201 W. Washington Ave.,P.O.Box 7162 Dane, 0/— 0 a 3 D <br /> IsconsIn Madison,WI 53707-7162 Site Address <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary aryo umbel o <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> NI/Check if Revision <br /> may be used for secondary purposes Privacy Law,s15.04(l)(m) <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> Property Owner's Name Parcel Number <br /> Mary Statz oaa-owes-tea-auto-3 <br /> Property Owner's Mailing Address Property Location <br /> 9IS5 GUM Z Rdi. IOW% NW 'k;Sao T °► N,R 13 E <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> C yosg Plat II S.7 W _5352:5 FAQ-NA <br /> II.Type of Building(check all that apply) ❑City <br /> Gel or 2 Family Dwelling-Number of Bedrooms 4 OVillage <br /> ❑Public/Commercial-Describe Use Qfownship Cant. <br /> ❑State Owned Nearest Road <br /> 1..c..Ct- )..-i(15,r141c4 tad <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use) piete line B if applicable) <br /> A. 1 Er New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to F r County to <br /> System Tank Only Existing System /rF��� <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number \ itj iygtietl�. <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use 0C1 <br /> 44❑ Non-Pressurized In-Ground 2113"Mound 47❑ Sand Filter �A,1F 50❑ Cotst&t*xptland <br /> 22❑ Pressurized In-Ground 41❑ Holding Tank 48❑ Single Pass ,,el, ' Line U/ <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 1 Zijq,-)\ <br /> V.DispersaUTreatment Area Information: %i''1�T/.�'y'Fht4 <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate Sy .. Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> to Do i2co4-t?- ) 44•1 ,S <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 I co -,,, - LAN, I tvita ie ✓ <br /> Dosing Chamber s — eco V. ti/ <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 /> kvldR 44 M4 filet z ,rb✓w W• .1Y14S �J c t'ReS 831- 0103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> C'307 ' may. V VJaur,akee, wi 53y417 <br /> VIII.County/Department Use Only <br /> Sanitary Permit Fee(includes Groundwater Date Issued Ism' gent Signature(No Stamps) <br /> Approved ❑ Disapproved <br /> Surcharge Fee) /, �V�✓� <br /> ❑ Owner Given Initial Adverse %G/ ,A (! <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 Inches In size <br /> SBD-6398 (R. 05/01) <br />