Laserfiche WebLink
eommerco wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Rkr h Le <br /> ff <br /> j fIS <br /> i Seo n s i n Madison WI 53707 7162 Sanitary Permit Number(m be Filled in by Co.) <br /> flnpartmerst of Commerce 404,5 <br /> Sanitary Permit Application Stale Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental 7936,2 3 3 <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(ifdifferent than mailing address) /nl <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary CJ <br /> purposes in accordance with the Privacy Law,a.15.04(I)(m),Slats. <br /> I. Application Wormation-Please Print All lnforimation 11C• <br /> Property Owner's Name Parcel#a 7 04 ff l-/oal- <br /> M&r Scalzo {85D m-'00notgo <br /> Property Owner's Mailing Address Property Location <br /> S 3 yd C i7B f� Gnvl. nl <br /> City,State Zip Code Phone Number / <br /> Section aft <br /> S od"6VW�� S'Yspo/ (circle one <br /> T //p N; R E od) <br /> IL'Type of Building(check all that apply) JJ Lot# <br /> ® I or 2 Family Dwelling-Number of Bedrooms P I Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> L1 State Owned-Describe Use CSM Number n 11 Village of <br /> / w- 11 �/ ( P M Town of <br /> IIL Type of Permit: (Check only one boa oa line A. Complete line B iif fap�pliccarble)`-( 1, <br /> A. Ay New System y 11 Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑ Permit Revision <br /> ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all tlsat apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade X Mound>24 in.of suitable sod ❑Mound<24 in,of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. ersal/Freabnent Area Llfonttation: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(st) Syalem Elevation <br /> 300 . 9 iso 33r. ?93 a"s <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallom Gallom Units <br /> New Tanks Fadsting Tanks r n <br /> Septic or Holding Tank 7s0 7So <br /> Dosing Chamber SO0 <br /> SBO <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation ofthe POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's SSiignature// MP/MPRS Number Business Phone Number <br /> 4le� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 776 e yu 3S Gve66/r,- <br /> VIII Cozen /De wtment Use Only <br /> Approved 11 Disapproved permit Fee Dafe Issued Issuing A 1-7 lure <br /> a 275 `' � <br /> ❑ <br /> Owner Given Reason for Denial 3 /J '� )1 �t�J Z0( <br /> IX.Conditions of Appmml/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the Counly only an paper not les than 8 in r 11 inches;in size <br /> SBD-6398(R.01/07)Valid thou 01/09 <br />