Laserfiche WebLink
Safety and Buildings Division County <br /> �� 201 W.Washington Ave.,P.O.Box 7162 'Dtn€J <br /> s�onsin Madison,WI 53707-7162 Sanitary Permit Number(to filled in by Co.) <br /> (608)266-3151 �j ,/ <br /> Department of Commerce `�,.�,a`1Se 0 1 -1 0 /" <br /> State an I.D.Number <br /> Sanitary Permit Application <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15.04(1 Xm) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information Caech rtal Tbivr+ 'TrA',1 <br /> Property Owner's Name Property Location <br /> Vertdian tier 'S NE ''A SA) 'A Section 20 <br /> Property Owner's Mailing Address <br /> T 7 N R S E <br /> C43.0 l S�vi-1.1'To1vte 1>. <br /> City State Zip Telephone Parcel# <br /> Mctot i son 1/91 53-713 17 OS-203-x 112-o <br /> Type of Building (Check all that apply) Subdivsion Name!CSM# Lot# <br /> fi 1 or 2 Family Dwelling-Number of bedrooms 5 <br /> '3Pvice fbllo,., 22 <br /> ❑ Public/Commercial-Describe Use ❑ City ❑ Village * Township of <br /> ❑ State Owned-Describe Use <br /> M'told le--tan <br /> art <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. INew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ES Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil ❑At-Grade ❑Single Pass Sand Filter <br /> ❑ Constructed Wetland ❑Pressurized In-Ground ❑Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter <br /> ❑Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Appl Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> -7'50 1.0 -750 -75o -r fci s1TE <br /> VI.Tank Info Capacity in Total No. Manufacturer Prefab Site Steel Fiber Pla- <br /> Gallons Gallons of Concr Con- Glass stir <br /> New Existing Units strati <br /> Tanks Tanks <br /> Septic or Holding Tank 1650 _ l 4050 t M EAp . A <br /> Aerobic Treatment Unit <br /> Dosing Chamber SOO — ej.-50 1 u 7 <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 lidP/MPRSW No <br /> Arore., W. Me`trhol2 - — !o_ 22 o)EA- <br /> Plumber's Address(Street,City,State,Zip Code Phone Number(Daytime) - <br /> cc:6k 3 c.-114- K Wav►eaIcce,WI 537 831•5/03 <br /> VV .County/Department Use Only <br /> .Approved ❑Disapproved Sanitary Permit Fee(incl Date Issued Issuing Agent S.: ature o S <br /> / W Surcharge Fee) <br /> ❑Owner Given 121-if 0 0 /0/20/06 <br /> Reason for Denial iT)) . <br /> IX.Conditions of ApprovaUReaso for Disapproval <br /> i <br /> I' <br /> OCT 1 P <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches 4 size 1 <br /> SBD-6398(R.01/03) <br />