Laserfiche WebLink
commerceml.gov Safety and Buildings Division County <br /> i201 W.Washington Ave.,P.O.Box 7162 Bet NLI f seo n s i n Madison,Al 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Oepartmerd of commence c504k/ <br /> Sanitary Permit Application State tion,/Number <br /> In accordance with s.Commm <br /> .83.21(2),Wis.Adm.Code,submission of this form to the appropriate governental Let ) <br /> unit is required prior to obtaining a sanitary <br /> submitted to the Department of Commerce. permit. Note: Application forms for state-owned POW Io are Project Address(if differemthan mailingaddress) <br /> Personal information you rovide may be used for secondary ���/I <br /> Eutposes in accordance with the PrivacyLaw,s.15.04(1)(m),Stats. / 0. ��Q N t° D r <br /> I. A licationInformation-please Pott All Information oZ <br /> Proper^j Owner's Name Parcel# O T•O$.O• -4d/ a1 O� <br /> /�O h /�t H ( uar�, rtacker All T MIC44ft lane. Eagan,ala ss/23 /S_ <br /> YA1- O18eeo <br /> Property pavner'e Mailing Address Property Location <br /> A -79139 Le.+ a r?r,e Rat. Govt.Lot <br /> City,State Zip Code Phone Number ''/. d 0 <br /> , Y., Section <br /> 5_ (673 BGriv ^�bd9cQcleme <br /> IILr Type of Building(check all that apply) Lot# T e4o N; R A4 E or(� <br /> Kx 1 or 2 Family Dwelling-Number of Bedrooms J 8 /Subdivision Name <br /> Public/Commercial-Describe Use <br /> Block# 4A PLAAYM AOTJW To✓l l ,�Je 6)skr- <br /> ❑ <br /> 11 City of <br /> ❑State Owned-Describe Use CSM Number El village of <br /> Town of CAle/ane(- <br /> 111.Type of Permit: (Check only one box on line A. Complete tine B if applicable) e7, 171_Q <br /> A. <br /> New System ❑Replacement System ❑Treahoent/H.1ding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Pemra Tramfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner. <br /> ��I,(V,(.T e of POWTS S stem/Com onent/Device: Check all that apply) <br /> [�J Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ Al-Grade 1]Mound>24 in.of suitable soil ❑ Mound<24 is of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. ' ersa amatment Area Information: <br /> Design Flow(gpd) Design Soicnion to( at) Dispersal Area Required(st) Dispersal Area Proposed(at) System Elevation <br /> °a • 7 yd 9 /aid W- 7 <br /> VI.Tank Wo Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o 0 <br /> New Tanks Existing Tanks <br /> � U y 3 m is C7 P. <br /> Septic or HoldingTank SQo sr�//yW K' <br /> ITChamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) /, Another's Signature <br /> MP/MFRS Number Business Phone Number <br /> k>/L/- f-/� k/N S / ✓� dl� �/ 7/ �G Q/S� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> d-7 >(0d /J4— w-e6,s{r., t , — <br /> VIII.Coon /De artment Use Ont <br /> Approved <br /> 11 Disapproved Permit Fee Date Issued Issuing Ag��iff,�Signalure <br /> $ -rte , <br /> El Owner Given Reason for Denial �i(J�yD .20{'�p/ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to romplete plata for the system and wlavit to tM CouNy aNy an paper out has this,8 in z 111nchea in-ire <br /> SBD-6398(R.01/07)Valid thin 01/09 <br />