Laserfiche WebLink
Safeand Buildings <br /> ion <br /> eommeece.wl.gov 201 W.Washi gtonAv.,P.OtsBox7162 conn ur <br /> seonsin Madison,WI 53707-7162 Sanitary Permit Number(to Tbefilled inbyCo) / <br /> wparlrnem d commerce J S 1�-O / W <br /> Sanitary Permit Application State Transaction Number —� <br /> In accordance with s.Comm.83.21(2),W is.Adm.Code,submission of this form to the appropriate governmental ? 15C>1993 <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(l m,Slats. �7 <br /> 1. Application Information-Please Print All Information 73 / a e- /r e <br /> Property Owner's Name Parcel# <br /> o Xtr1 17 o -a 3 a&--5-1 -- o a o <br /> Property Owner's Mailing Address <br /> / Property Location <br /> /e1 a / / 11/.01&-,e Sf Govt.Lot <br /> City,Stale Zip Codd/e'' PhoneNumber �—y, !4, Section <br /> /IA CA "I" 5�7� ��f ocle one) <br /> 11.Type o Lot# <br /> Building(check all that apply) T N; R�— <br /> I or 2 Family Dwelling-Number of Bedrooms 1 Subdivision Name <br /> Block# O2K df 1 iOr <br /> ❑Public/Commercial-Desenbe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> kTown of L 4/ C y <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) — —O l— ' <br /> A. El New System kReplacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. El Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer in New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent(Device: Check all that apply) <br /> ❑ Non-Pressurized ln-Ground ❑ Pressurized In-Ground ❑At-Grade Mound>24 in.of suitable soil ❑Mound<24 inof suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis er liVIrmatment Area Infomration: <br /> Design Flow(gpd) Design Soil Ap lication Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed i sf) System Elevation <br /> d - P .I o o -5 a 0,/27 7, 9 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units E V y <br /> New Tanks Existing Tanks o z: <br /> 0 <br /> d V v; y 6n <br /> Sepnc or Holding Tank <br /> Dosing Chamber �t L d7 I / I <br /> VII.Responsibility Statement-1,the undersigned,assume responsibinty,for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature <br /> igna MP/MPRS Number Business Phone Number <br /> 17 8d <br /> Plu%ber's Address(Street,City,State,Zip Code) ' <br /> AX. F 164 <br /> VIIL County/Department Use Only <br /> El Approved 11 Disapproved Permit Fee Dale issued Issuing a Signature <br /> [IOwner Given Reason for Denial S� 7 S �9 J(XtG GVl s <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attest-to compkh plow for We system and submit to the County only oo paper not Imo Wan 8 in 111 inehm in sire <br /> SBD-6398(R.02/09) <br />