Laserfiche WebLink
commercemi.gov Safety and Buildings Division Co �' <br /> 201 W.Washington Ave.,P.O.Box 7162 K r n fi"`l) L <br /> yf i sc o n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Deparlmem of Commerce .54 03 3 S JQ <br /> Sanitary Permit Application State Tan actt on Nuu��mber <br /> In accordance with s.Comm.83.2 1(2),Wis.Adm.Code,submission of this form m the appropriate governmental pyg4' Kir,et.) /fl <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Pro) ct Address(if different than mailing address) 1, , 1l <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary //�� (v\_I <br /> purposes in accordance with the Prwac Law,s. 15.04(1 m),Slats. ,20 3 85 l+ � <br /> I. Application information-Please Print All Information ova ne <br /> Property Owner's Name 1 /(� Parcel# <br /> 1 -ev a,� 3 LS 07-034-2-37-/6-3V5 05.0K- 012OW <br /> Property Owner's Mailing Address (�I Property Location A � <br /> Crow.Lot_ r S4Mt 5 4(0 7�" <br /> City,Stat // LipiCCOcle Phone Number �[ y, _�/,, Section 3 <br /> �'-e I G W r TO 3 -7 /S 3,DO— T 7& 'J y �cucle on <br /> II.Type of Building(check all that apply) Lot# T��N; R /t7 E or Z <br /> IX 1 or 2 Family Dwelling-Number of Bedrooms \3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> / // <br /> ❑ CSM Number ❑Village of <br /> State Owned-Describe Use JRTown of e, <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) _ j <br /> A. ❑ New System ❑Replacement System ® Treatment/ X Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. El Permit Renewal ❑Permit Revision <br /> ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> 0. <br /> Before Expiration Owner / �7T C39 �_ /S-88- <br /> tV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> INon-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal(Trestment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ` 0 o v <br /> New Tanks Existing Tanks <br /> o = 2 g a= <br /> P. U rn y h iW C7 R. <br /> epn rHolding Tank <br /> IC o0o v � <br /> Dosing Chamber A' wD <br /> VII.Responsibility Statement-f,the andersigae ,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu ber's Signature MP/MPRS Number Business Phone Number <br /> ��S oer � Z _S2z 7/Sa6-�'6acP <br /> lumber's Address(Street, ny,State,Zip Code) <br /> VIII.Coun /De artment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial <br /> 3.25� 6 A-5 20,0 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Sol/ JUNE lyd(C O e MG S Seo D - rfma— %J kja( 6y P64W&, aF 91131 JO IS <br /> Con515"64 Wrfk -C*t 6-er6es 06bs <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 1I inches in size <br />