Laserfiche WebLink
Safety and Buildings Division County <br /> ..a. „ 201 W. Washington Ave., P.O. Box 71(2 �tyl� L%-- (.'s i I <br /> iseonsr►n 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 L( I 1 o <br /> may be used for secondary purposes Privacy Law,s15.04(((m) ❑ Check if Revision <br /> I. Application Information-Please Print All Information State Plan I.D. Number <br /> 1 7 3e, <br /> Property Owner's Name <br /> Parcel Number <br /> Cole J. Cent-1st-1n- e xp OLZ-C' tI- 2613.247-°i <br /> Property Owner's Mailing Address Property Location <br /> h/1Fa51V2t N1/4 .,t SW IA:S2I T `1 N.R II is <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> 7 .- <br /> Subdivision Name CSM Number <br /> .a.try !m w t e , 1N11 53 g 0 HervLstcticl Es(• – <br /> II. Type of Building(check all that apps <br /> ❑City <br /> 1 or 2 Family Dwelling-Number of Bcdrdo <br /> OVillage <br /> ❑Public/Comrncrcial-Describe Usc <br /> NTownship d 13nS3-Ut <br /> ❑State Owned Nearest Road <br /> Cvrdda, CrPS-t <br /> III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> A. I r.Sk New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> System Tank Only Existing System <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 ❑ Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Wetland <br /> 22❑ Pressurized In-Ground 41❑ Holding Tank 48❑ Single Pass 51 ❑Drip Linc <br /> 45 At- Lade/? 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V. Dgiperr.[l/'Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percalation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Mir../Inch) <br /> SET Elevation <br /> ("CD 12D)(- ? 124:6-(-1/4.Z m S — Si S��AT <br /> SITE <br /> VI.Tank Info Capacity in . Total Number Manufacturer Prefab Site I Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> Ncw Existing <br /> Tanks Tanks <br /> Septic or Holding Tank 's - 1l0 50 t tvm,cte <br /> Dosing Chamber ea) _ 800 1 ( y <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 /> strew Heim-j2. ./- _ bU WI a3Otos 031-3(03 <br /> Plumber's Address(Street,City,State.Zip Code) <br /> ( 33Q7 }-Wy. K.. lAilunakee• v I 53Gc 7 <br /> VIII. County/Department Use Only <br /> If <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agent Signatur No m <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse <br /> Determination (!7U _30-0 74,./z:N1 . / <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> L <br /> Attach complete plans(to the County only)for the system on paper not lc.0 than 81/2 x 11 Inches In size <br /> ("DTI 4-1/"No in nC rn,. <br />