Laserfiche WebLink
commerce.wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 g 4 r K C 44 <br /> i s c o n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) 1/ 11 <br /> Department of Commerce ,55 11 /z <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.8321(2),Wis-Adm-Cade,submission of this form to the appropriate governmental 11"2286 <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms 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 se dary <br /> puiposes in accordance with the Privacy Law,s. mmnn <br /> IAlnI. Application Information-PleasePrintlUflbw G <br /> O <br /> Property Owner's Name Parcel# <br /> I-2Jer(L, -� Wirc a 44•� �t+-er 07-OW-D-37-19- <br /> 30-3 o -000 <br /> ­ <br /> Property Owner's Mailing Address / Property Location 611000 <br /> -0 S1� A H e ^-';'�e R d, Govt.Lot <br /> v <br /> City,State Zip Code Phone Number � /�' <br /> _� Vl/'/., JW'/., Section o <br /> {eQ vt V 1 f 'ft W 0 lis -6� uclne <br /> w T _N; R� Eoeor� <br /> II.Type of Building(c eck all that apply) Lot# <br /> 1 or 2 Family Dwelling-Number of Bedrooms 3 _ Subdivision Name <br /> Block# <br /> D Public/Commercial-Describe Use <br /> ❑City of <br /> D State Owned-Describe Use CSMNumber El Village of <br /> XTownof ��.e— <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) 7�- _ <br /> A. I%NewS tem <br /> ys ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Otho Modification to Existing System(explain) <br /> B- D Permit Renewal ❑Permit Revision D Change of Plumber D Permit Transfer to Nev, List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> D Non-Pressurirxd In-Ground D Pmsuriud In-Ground D At-Grade 09 Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil _ <br /> D Holding Tank D Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersalfrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> �/S0 I VS-0 I V5-0 Cl-I. <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a o y v <br /> New Tanks Existing Tanks '« C U 7 -6n <br /> .. <br /> v o m <br /> i7 W <br /> Scmx or folding Tank i Ovo y, <br /> Dosing hamber A <br /> _ x <br /> VII.Responsibility Statement- 1,the undersign ,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) PI tier's Signator MP/MPRS Number Business Phone Number <br /> Ide IS 'I.C� ilr � 7rf <br /> Plumber's Address(Street City,State,Zip Code) <br /> 8Y-S- r s�r3 <br /> V Il.County/De artment Use Only <br /> Approved D Disapproved Permit Fee Date I <br /> ssued I Issu/i/u{/�-A/ge�nt Signal e <br /> ❑Owner Given Reason for Denial $gr75 q-'3_1 <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 Iess than 8 I2 x 11 inches in size <br /> SRD-6398(A 02/09)Valid thm 02/11 <br />