Laserfiche WebLink
Safety and Buildings Division Count (� <br /> Wi 201 W.Washington Ave.,P.O.Box 7162 13 4 h Q of- 0(,g <br /> sc onsin Madison,WI 53707-7162 Site Address <br /> t <br /> Department of Commerce <br /> Sanitary Permit Application sarutary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide O o ca D <br /> may be used for secondary purposes Privacy Law,s 15.04(1 Xm) Check if Revision <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> 6 Owner's Name Ut. Parcel Number <br /> k d(; - bill —3c, ( "4017 .. <br /> Property Owner's Mailing Address Property Location <br /> PO a0.( IL, J•C'/. 6C/.;S-TO T N,R // n <br /> City,State 1 Zip Code Phone Number Lot N <br /> a 4-� w', — + Subdivisio <br /> ,,L, CSMSNnmber <br /> it. ype offilding(Check all that app■.) Al ❑City <br /> ,To r 2 Family Dwelling-Number of Bedroo , a ! nr%a <br /> ❑Public/Commercial-Describe Use I .,• I 1 ❑Village <br /> ❑State Owned I - Nearest ip et:S'dti 1 <br /> Nearest Road <br /> fANF (*MINTY FNVIRP VFNTAI '114?-4-‘.- -re <br /> III.Type of Permit: (Check only one box on line A. Numbetp)tl041oxinterylAse.) (Complete line B,if applicable.) <br /> A. 3 New System 30 <br /> ank meet of 6 D s°System For County use <br /> 12❑Replacement S y Existing yst ty <br /> B. ❑Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.T�yppee of POWT System: (Check all that apply. Numbering is for internal use.) <br /> 441 on-Pressurized In-Ground 21❑Mound 47❑ Sand Filter 50❑Constructed Wetland <br /> 22 0 Pressurized In-Ground 41❑Holding Tank 48❑Single Pass 51❑Drip Line <br /> 45❑At-Grade 46❑Aerobic Treatment Unit 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) I /mss Elevation 10 t�S <br /> 6C-0 11.43(3 l7z b s >� Z I °1 �ot 1 <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 1200 j 200 ' <br /> Dosing Chamber Cgt J ` I <br /> VII.Responsibility Statement- I,the unders .ned,assume responsibility f / •.n of the POWTS shown on the attached plans. <br /> P(dII 's Name n PI , ." ;Si; lure I�191S19:t. Number Business Phone Number <br /> � ct ‘i ", Z ) z6tf-1 °1710-.6z.3-+,5/1 <br /> Plumber's Address(Street,City to Zip 4 ) .gc) a tut,A110L6 (P4- S--P32-5- <br /> N 5c> '( !fru_VIII.County/De artment Use Only <br /> Disapproved Date Issued Issuing Agent Signs S <br /> Approved ❑Owner Given Initial Adverse Sanitary Permit Fee(include Groundwater <br /> Surcharge Fee) s <br /> Determination o),p _ <br /> //:-...3c) <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> • Z-L`i 'sl $t.. b4 Z,.VALLA7JZtP4 <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 a 11 inches in size <br /> SRn-639R(R. 05/011 <br />