Laserfiche WebLink
commerce.wl.gov Safetyand Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 C1 r A) <br /> isco n s i n Madison,WI 53707-7162 Sanitary Pe it Number(to be filled in by Co.) <br /> Department of Commerce di 1 l 1 <br /> Sanitary Permit Application State Transaction Number 660JJJ <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental elA e..) <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 <br /> purposes in accordance with the Privacy Law,s.15.04 1 m,Stats. �� /c �� e �� <br /> 1. Application Information-Please Print All Information s7 <br /> Property Owner's Name Iy/ Parcel# <br /> 151 LC104-3 <br /> Property Owner's M ng Address y/1 / Property Location <br /> -5 /V G Govt.Lot <br /> City,State Zip Code Phone Number Section <br /> St r e s.� Sy� 7Z y _may y (circleone <br /> II.Type of Building(check all that apply) Lot# T N; R_/-� E o <br /> or 2 Family Dwelling-Number of Bedrooms a �- Subdivision Name <br /> � <br /> Block# <br /> D Public/Commercial-Describe Use -� <br /> ❑City of <br /> El State Owned-Describe Use - CSM Number DVillage of <br /> rllown of S I ✓ e- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) _ <br /> A. D New System �KRe laccmcrt System <br /> ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. D Permit Renewal D Permit Revision D Change of Plumber D Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner a 0r7 0 81 <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> sr <br /> tNon-Pressurized In-Ground D Pressurized In-Ground D At-Grade D Mound>24 in.of suitable soil D Mound<24 in.of suitableoil <br /> D Holding Tank D Other Dispersal Component(explain) D Pretreatment Device(explain) <br /> V.Dis ersaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdso Dispersal Area Required(sf) Dispersal Area Proposed Is p System Elevation <br /> 7 6 <br /> 300 , yzY ar0 .7b <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> 0. V h t4 <br /> Septicor Holding Tank 40U __ OO <br /> Dosing Chamber S O L <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> ZZ769/ 3 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> a 5'/ Sii e 5- <br /> VIII. <br /> VII .Coun /De artment Use Old <br /> Approved El Disapproved Permit Fee Date Issued Issuin gent Signature <br /> 11 Owner Given Reason Por Denial <br /> IX.Conditions of Approval <br /> ,5*0m deaaiaoh : 9700 6* 97. 70 A Ak t as 6:-v4 .» l,.m Y SDr.,L awed <br /> vs/05 Jg&ade Arm OF 0r5l"41 fel{ 115 „5011 i*rt ly sc-H - <br /> Attach to complete pians for the system and submit to the County only on paper not less than 6 to x 11 inches in size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />