Laserfiche WebLink
commerceml.gav Salety and Buildings D"',i..n, County -------'---- '1 <br /> 201 W. Washinglon Ayc_ P.U. Rox 7162 �y JIII <br /> isconsin <br /> Nl;ll�lsllll.WI 53707 7162 Sanilmy Parmil Nmmhcr(lo be filled in by <br /> Department of Commerce ,/� <br /> Sanitary Permit Application sl°'c'Pr%�.acli^n Nmnber In accordance wild s.Comm.83.21(2).Wis.Adm.('ode,submission of lho,Ibnn lu the appropriate yocc+nmcnlal <br /> unit u required prior to obtaining a sanitary permit. Nulct Application limns fur slalc-..^rind POW[S arc <br /> submitted /o the Department of Commerce. Personal information pun pnrvidc mal' he uvcd for secondary Ii ojecf AJdress(if dilTcrcul than mailing addrevrj-- <br /> m oses in accordance with the P,iVaeV law,s. I,;nmi,(m),Slats. <br /> 1. Application Information-Please Print All Information 5 � <br /> Prgmmty Owner's Name Parcel 11 <br /> f+ r o3a 020 X333 o��a� - l <br /> 11 operly owner's Mailing Add/rens 1}Uperty Location /1 <br /> A-6 / c <br /> (invl.Lod <br /> (11y.Slate lip('oJu I'hnne Numhcr --._ _ , I <br /> cr sy�'93 G- Sf6 9 � -A)-- __ _3 <br /> timi _ 3 <br /> ( circle one <br /> IL 7)pe of Iluilding(check all that apply) �7 Lot,I -- I l N; R 16. I±.o� <br /> _1-1u2 Family Dwelling-Numbernf Bedrooms pC Subdiviaim,Namc -----'-' <br /> Block e - <br /> ❑PublidC°mmcrcial-Describe I.N. - <br /> _. <br /> El City of <br /> ❑ Stale Owncd-Descrike Ilse _- (SAI Number ❑ Village of <br /> IIL'1;ype of ferulic (Cheek only one box on line A. ('oulpicte line Il if applic:lble)EOrrryyy,,, ''''''ystem 9-Replacement System ❑ 'lic;ltmcnLilnlding'I'ankRcplacunndOnly ❑ Olhcr Modification to lisisling Syslon(ceplain) <br /> Rnewal ❑ permit Revision ❑ ('Lane of Plb ❑ ' ' Lill Previous PermitNumberand Dale IssuedpiratiUn f)wncr <br /> 1\'.1fv a of POW'1'S S stenn/Cnnr anent/Device: Check all that a, B') —'— <br /> m-PrcvxurvcJ In-(imund ❑ I'r'cssw'izcJ In-Ground ❑ :\l-tirade ❑ Mound ZJ in.ul'su ilablc soil ❑ Mound ,:24 in.ul'snitahlc xuil <br /> ❑ Bulding'fm,k ❑Olhcr Dispersal Component(explain) - <br /> _. .. _. ❑I}ctrcahncnt Ucviuc(explain) <br /> V. )is crsal/I'rcamncut Arca Information: - <br /> Design Plow(gpd) Design Soil Application Rate(gpdsl) Dixperval:\rca RcyuiruJ(sl) Uixpa'sal Arca Proposed(sO tiy4lVln lilcvatian <br /> a � s oa CL <br /> VI.'Tank Info Capacity in 'I incl 00l hianuliclurer - -'- <br /> Gallons Gallons Units °i c <br /> Ncw'rmJ:s a E ° <br /> lisisling'I ranks <br /> Scplic,r Ilnlding'rank � `- '--- 7 � Cl <br /> Dosing Clamhcr �O �� <br /> VII. Responsibility, Statement- 1,the undersigned,assume rrspunsibilih'fur incl aiLdion urrhr I'O\V'I'S shown on the altachnl plans. <br /> 1'lumheis Name(Print) Plumber's Signamie NIRMPRS Number 13usincss Phone Number <br /> l�511)d � � z z 769/ <br /> vinum�ber'9 Address(Street.City,Slate.zip Codc) <br /> LJ Off( r� s/^ E./l� G✓ __�_yd 7..[. <br /> VIII.Countyl0eparhient Use Only --- <br /> Approvcd ❑ Disapprove) Permi�Jt Pec Ualc hsucd -r Issuin Signature --- <br /> O Owner(liven Reason for Ucnial 5 /���� (�' *1 107 <br /> Q/ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Arhrh m rumplrm pl.as rur rhe aysrnn rend.ul.na to tiv('aunty may un,.,Mr nor Irm than a,n•11 brise to <br /> SIM-0398(R.01107)Valid lhru OI,09 <br />