Laserfiche WebLink
tbmmerceml.gov Safety and Buildings Division Countyp <br /> 201 W.Washington Ave.,P.O.Box 7162 �Ju rN <br /> t!"rtimard sco n s i n Madison.WI 53707 7162 Sanitary Permit Number(to be filled in by Co.) <br /> of Commerce <br /> Sanitary Permit Application State Turns Number <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental (� 4w P.as) <br /> unit is required Prior tu obtaining a sanitary permit. Now: Application forms for state-owned POWTS are Project Address(it different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> plMses in accordance with the Privacy Law,a.15. lxm),Slats. <br /> I. Appliution Information-Please Print All Informati L u N!M s N 00 <br /> Property Owner's Name Par-I#6 <br /> e /S4-01& ss <br /> k e J.t d 4/ 6 s <br /> ears Rees � omh mr coo <br /> Properly Owner's Mailing Address Property Location <br /> �' b O Q'FN /�✓C Sc� GovLLot� <br /> City,State Zip Code Phone Number b <br /> ys y., Section a <br /> CA a+b a•;e cncle one <br /> IL Type of Building(check all that 1yrO O 8 Lot# T °'f/ N, R /.r' Eo f <br /> I or 2 Family Dwelling-Number ofBedrooma r 3o Subdivision Name <br /> Block# <br /> ❑PubadCommereial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number [I Village of <br /> Yd D (m19 Ir <br /> Town of fir/IBJ <br /> 111.Type of Permif: (Check y one box on line A. Co replete line B if applicable) <br /> A. <br /> New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revise. ❑ Change of Plumber 11Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com .nent/Device: Check all that appyl <br /> . Non-Pressurized In-Ground ❑Pressurized hr-Ground ❑ At-Gmde ❑Mound>24 in of suitable soil ❑Mound<24 in,of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DI s ersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(af) Dispersal Area Proposed(sf) System Elevation <br /> 3s, o 1 . 7 40l g e*3/r 9/• .s" <br /> VI.Tank Info Capacity in Total #or Manufacturer <br /> Gallons Gallons, Unita <br /> New Tenks Exictirrg Tstrks w u <br /> Septic or Holding rank <br /> Dosing Clamber <br /> VII.Responsibility Statement-L 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 /> A?ic.le- 110 /CIs,1 t -e /rf �ieC ,,^/ 7/,f=fbf-U/s] <br /> Plumber's Address(street,city,state,zip Code) <br /> 7 76 O A" 3S U�d.jst rf a s—S'/as � <br /> VII Court /De artinent Use Ont <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing rgnaturs <br /> ❑Owner Given Reawn for Denial <br /> IR.Conditlmts of ApprovaVReasons for Dimpproval <br /> Attach as complete plans for the system and suhmlt to the umay,only an paper nut has than 81a a 11 Inches in rise <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />