Laserfiche WebLink
eommereeml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 13(A Y, <br /> j f i sego n s i n Madison,WI 53707 7162 Sanib Permit Nomber(to I filled n by Co.) <br /> Department of commerce MR <br /> �— <br /> Sanitary Permit Application State Transaction Number <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 differeat than mailing address) <br /> submitted to the Department of Commeroa Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,a.15.04(1)(m),Stab. <br /> L Application Information-Please Print AB Information 3 <br /> Property Owner's Name Parcel# <br /> /9n4<1017 Ze an 2- (�J+ S a3a-�3o - <br /> Prop"Owner's Mailing Address JProperty Location <br /> /S3 90 36Ii h S". Jl f, GovL Lot <br /> City,State Zip Code Phone NumberYy 30 Y., Section <br /> .ffi 11W- 4cV An Al SSo Bek (circle one) <br /> IL Type of Building check all that apply) Lot# T 9/ N; R /S E 000 <br /> a a Subdivision Name <br /> 9lor2Family Dwelling-Number of Bedrooms a, 3 4- � boa <br /> kBlock# <br /> ❑Public/Commercial-Deamibe Use <br /> ❑City of <br /> ❑Stare Owned-Describe Use CSM Number ❑Village of <br /> ATownof Jr <br /> III.Type of Permit: (Check <br /> q only one box on tine A. Complete tine B if applicable) <br /> Jd <br /> A. ❑New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modificatim to Existing System(explain) <br /> H. ❑ Permit Renewal ❑Permit Revision ❑ Chmge oFPlumber <br /> ❑Permit Tramfer to New Liat Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> ,rx Non-Pressurized In-Oround ❑Pressurized In-Ground ❑ M-Grade ❑Mound>2l ir.of smtabte soil ❑ Mound<24 inof suitable soil <br /> Holding Tank 0 tither Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dis ersaYrteatment Area Information: <br /> Design Flow(gpd) Desigo Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(at) System Elevation <br /> 30o . 7 'VOL 5 43,i 9/•s— <br /> VL Tank htfo Capacity in Total #of Manufacturer <br /> Ganem GaHom Urita i ,N <br /> New Tmrks Exhang <br /> TaAsis <br /> a <br /> Septic or Holding Teel: g0O 90Q <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Sigmturo MP/MFRS Number Business Phone Number <br /> 4'/e- f/p E, f / � ZZ ,IAs941r1 7/s_ FG i-- 4/x7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ,1776 .y 3s Wed-4?1e � wr s vP93 <br /> IL County/Department Use Only <br /> red 1 ❑Disapproved Permit Fee Date Issued laaumg gem Signature <br /> ❑(Neuter Given Reason for Denial a /02 Maz- I <br /> IK Conditions of Approval/Reasons for Disapproval <br /> Attach to compete pieces for the ryatem and wbmk to the Coumy only on paper not less them a in a 11 inches In sine <br /> SBD-6398(R.01/07)Valid thm 01/09 <br />