Laserfiche WebLink
commerce.wi.gov Safety and Buildings Division CoWTyV 1-nnP <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> y(i sco n s i n Madison,WI 53707-7162 Sanitary Permit umbar(to be f led in by Co) <br /> Departmem of Commerce O I {, <br /> Sanitary Permit Application State Transaction Number V <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental ` <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 secondary O <br /> purposes in accordance with the Privacy Law,s. 15.04(l m,Stats. <br /> I. Application Information—Please Print All Information <br /> Property Owners Name Parcel# <br /> all a �t lwtcl .�t, <br /> Property Owner's Mailing Addrdss I Property Location <br /> D (o S C' r r e ( Govt.Lot } �I <br /> City,State Zip Code Phone Number -Al y, .S ig %, Section� <br /> refs 6Vr I S� FSyD WE bo"9 -aw�rb rcleon <br /> TN; AEo <br /> II.Type of Building(chick all that apply) Lot# <br /> rW I or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑PubliclComatercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of � )) <br /> Town of IN t�D 1 V�Qf <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A_ ❑ New System p;g RePlacemem system ❑Tnemment/Holding Tank Replacement Only Other Modification to Existing System(explain) <br /> ) <br /> B. El Permit Renewal El Permit Revision ❑Change of Plumber El Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent(Device: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ,Holding lank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaffreatment Area information: <br /> Design Flow(gpd) I Design Soil Application Rate(gpdsf) Dispersal Ates Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> So <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units E o v <br /> New Tanks Existing Tanks <br /> E c 2 a — <br /> a <br /> Septic 4<=9_T--V <br /> oldingT "')(7 yq� '1 6'V woo ' <br /> Dosing Chamber OC <br /> VII.Responsibility Statement- 1,the anderaigne assume responsibility for installation of the POWTS shown on the attached plans. <br /> yPyI �her'.s Name PI ber's Signature MPMiPRS Number Business Phone Number <br /> tut° S f- �.C� 22 X22 /S �� ( - <br /> Plumber's Address(Street,City,State,Zi Code) <br /> ler 57" <br /> V op.Coun /De artment Use Onl <br /> pproved ❑Disapproved Permit Feer ��pp--�� QDate Issued <br /> {�-� [ssuin gent Signature <br /> ❑Owner Given Reason.for Denial $ 375<Jo I�� (V <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 />