Laserfiche WebLink
ON CQMPUTERISCANNED <br /> commeree.wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 BµNn -e4 <br /> i seo n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> Department of corntrrerce .�- I -5-3Z2-79 <br /> Sanitary Permit Application Stater ansaction Nu <br /> ynm <br /> ,be <br /> 'r, ' ll <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental W HTiY 1`�I a ) V" <br /> unit is required prior to obtaining a sanitary permit Note: Application foma 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 <br /> puMose,in accordance with the Privacy Law,e.15.04(1)m,Stats. /�`/ n <br /> I. A licatim Wormatim-Please Print AD Information / <br /> Properly Owner's Name Parcel# e Y Bal a d HD /IV O <br /> w.+irr: C�4.geMLrC. SE2sscN ) 4p41 Ow } <br /> �'Y1iKG o�rrt u J /S /y,s— eddoo o v iso <br /> Properly Owpner'�Mailing Addrme /C�� If, View DP Property Location <br /> N N 14;0 K t s^. J (_ VALLEV M 55/2 Govt Lot <br /> City,State Zip Code Phone Number <br /> Y., Y., Section 7 <br /> AIM e In A/ S3'-Hv9 `/ ]a(D O4/.t (circle one) <br /> IL Type of Building(check all that apply) Lot# T 4D N; R /4 E <br /> I or 2 Family Dwelling-Number of Bedrooms 3 1 Subdivision Name <br /> PubEdCommereial-Describe Use <br /> Block# 1JJra1(ToA of 6aizrU Aq ITIOA) To <br /> ❑ <br /> ❑City of <br /> ❑State Owned-Describe Uae CSM Number ❑Village of <br /> llf Town of J^'e 6 <br /> III.Type of Permit: (Check only one boa on lime A. Complete line B if applicable) <br /> A. ry <br /> ay New System ❑Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑permit Transferm Nce, List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> ,SIV.T of POWTS stem/Com ck ertuDevice: Chean that apply) <br /> I&Non-Pmssurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 m.of suitable soil ❑Mound<24 im.ofauitable soil <br /> ❑Bolding Tank ❑(31her Dispersal Component(explain) ❑Pre ratmentDovicc(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdaf) Divpenol Arm Required(ad) D'epereal Anes Proposed(sf) System Elevation <br /> q I . S' 9e o 9D o q3 , 40 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Getting, GaBom Unita $ <br /> New Tanks Existing Tanks $ b a <br /> Septic a Holding Ted` zoo O / /C. ..... <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation ofthe POWTS shown on the attached plana. <br /> Plumber's Name(Pr'vr//t) Number's SoignaNre �j W1APRS Number Bueineee Phone Number <br /> /G/L <br /> Number's Address(Street,City.State,Zip Code) <br /> ^7"'O /' c r �5— W-ebferr G+/T Sy693 <br /> VIIL Conn /De armrest Use Only <br /> fi(Approved 1 ❑Disapproved Permit F�= Date Issued Issuing igmture <br /> ❑Owner Gives Reaeonfor Denial -* Amu /x , <br /> IX.Cmditims of Approval/Reasom for Disapproval <br /> RW IS'4 . ,4,y X56 3/0 ZOI a <br /> Mesh to complete plane far the system and submit to the County only en paper ant rare than 8 in all Inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />