Laserfiche WebLink
commerce.wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 k r h eTI <br /> i s c o n s i n Madison,WI 53707-7162 Sanitary croni Number(to be filled in by Co.) <br /> Departmem of Commerce <br /> Sanitary Permit Application State Transaction Number }` <br /> In accordance with s.Comm.83:21(2),Wis.Adm.Code,submission of this form to the appropriate governmental T <br /> unit is required prior to obtaining a sanitary permit. Note. Application forts for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary C) <br /> purposes in accordance with the Privacy law,s.15.04 t m,Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> LCidG/r-r.t Zi t ltµQ-Y A -�94707 07ftOSL-2^91•iS-O7-( eL-oOo-Ol <br /> Property Owner's Mailing Address Property Location <br /> S4Sl <br /> Otd 3 d Go'v't.Lot <br /> � <br /> City,State Zip Code Phone Number �y, t1E y, Section <br /> r S t/� a 71S loft(, - �3 9 I' (circle one <br /> K r T 7� N; R1C -Eo <br /> II.Type of Bu 1 ing(check all that apply) Lot# <br /> 19 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ village of <br /> t&Townof. Swiss <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System 19 Replacement System ❑Treatment/Holding Tank Replacement Only ❑Olha Modification to ExistingSystem ys tem <br /> (explain) <br /> B- ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Pemdt Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onentWevice: Check all that apply) <br /> 56 Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in,of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sr) Dispersal Area Pr <br /> 3 Od . 7 <br /> 4GallonsUnits <br /> n sed(st) System Elevation <br /> VI.Tank Info Capacity in Total Manufacturer O <br /> Gallons New Tames Existing Tanks w c Utw r7Septic or olding TankX <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu' tier's Signature MP/MPRS Number Business Phone Number <br /> e(S er t3asaa9 714- <br /> Plumber's Address(Street,City, tate,Zip Code) <br /> -7 8'e S GI, •,. I,t]��s�r w: 6'f3 <br /> V I.Count /De artment Use Only <br /> Approved El Disapproved Permit Fee //�� yDate Issued Imm gent Signature <br /> ❑Owner Given Reason for Denial $�/�lJ•UV U—I10-� rn7V _ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inches in size <br /> SBD-6398(R.02/09)Valid thou 02/11 <br />