Laserfiche WebLink
t:ommerce.Wi.gov Safety and Buildings Division County /. <br /> 201 W.Washington Ave.,P.O.Box 7162 u r o e 1t r <br /> 'Wisconsin Madison,Wl $3707-7162 Sanitary P Tit (to be filled in by Co.) <br /> epartmenmme <br /> t of corce Z <br /> Sanitary Permit Application State Tmnsac on 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 forma for state-owned POWTS are Project Ad a(if different than mailing address) <br /> submitted. m the Department of Commerce. Personal information you provide may be used for secondary <br /> Purposes in accordance with the Privacy Law,a.15. 1 m Slats. <br /> L Application Information-Please Paint An Information <br /> Property Owner's Name Parcel# <br /> Xr/af+ tT,rc Pee oiA %L3,4 otL -roo <br /> Property owner's Mailing Address Properly 'on <br /> S--f ''6 L. /?d A Gnvt Lot <br /> city,state Zip Code Phone Number <br /> S W Ys, f Y., section_ <br /> �(/F.�tfr� WS S`r1 ef9.3 (circle one) <br /> IL Type of&dMing(check a0 that apply) Lot# T c,'0 ; R /.! E or <br /> I or 2 Family Dwelling-Number of Bedroom Subdivision e <br /> Block# <br /> ❑Publi./Comm <br /> mcial-Describe Use <br /> ❑City of <br /> 11 State Owned-Describe Use CSMNumber ❑Village of <br /> ®Tower of wr./e.fs <br /> IDL Type of Permit: (Check Only one bm on lite A. Complete line B if applicable) <br /> A. New System ❑Replacement System ❑TreatmcnVHo Tach Ianement <br /> Dh8 Rep Only ❑Other Modi tion to Existing System(explsiv) <br /> B. Permit Renewal ❑Pernrit Revision ❑ Change of Plumber ❑Permrt Tramfer on New tI'Mur-FarmitNumbarandDatchsued <br /> Before Expiration Owner <br /> IV.Typeof POWTS stem/Com ent/Device; Check an that apply) <br /> JaNm-Presem¢ed)n-Ground ❑Pressurized In-Ground ❑At-Grade ❑Momd>24 in.of suirzbe sod ❑Mound< ia.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(exphm) <br /> V.Dis ersal/frest hent Area Information: <br /> Design Flow Wd) Design Soil Appliodion Rate(gpdsf) Dispersal Area Required p equ (at) Dispersal Area Proposed(at) System Elevation <br /> 3e0 . 7 94049 4-3f- 433. O <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Galloon Gallons Units U c <br /> New Tanks fixiuhug Tanks <br /> u a E g a? m <br /> Lt:U h m rn W C7 6. <br /> Septic or HobJing Tark a'i0 v Q�Q / .SIeA W X <br /> Doaog Chamber <br /> VIL Responsibility Statement-L the undemignM name responsibility for installation of the POWTS shown on the ata hed pluns. <br /> Plu nocr 8 Name(Print) Plumber's Signature / MP/MPRS Number Business Phone Number <br /> /?/G/G lelop le r nJ /G� /Y At rAS-/ <br /> Plumber a Address(b'teet,City,State,Zip Code) <br /> ,17760 y� 3-ir— y/Qbs�r _X. <br /> Se/gri� <br /> VUL Conn /De arhnent Use ltd <br /> 4!1Approved ❑D®approved Pum�fit I= Date Issued Issuing Trans <br /> ❑Owner Given Reason for Denial S ;Z5) 6 o 7 <br /> IX.Contntions of Approv&YKeasoro for Disapproval <br /> Attach to cons phos for the gstaw ad mhwh rotlw Coamy aNympaper mt len tions lax1lhahn size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />