Laserfiche WebLink
commereeml.gov Safety,and Buildings Division Comity <br /> 201 W.Waslungton Ave.,P.O.Box 7162 <br /> jf i seo n s i n Madtanit Wl 53707-7162 Sanitary Permit Number(to be filled in by C-) <br /> Department rA Commerce 53 2 /M <br /> State Transaction Number <br /> Sanitary Permit Application ,oAj <br /> - <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: Applicatien forma for,state-owned POWTS me 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 N accordance with the Privacy Law,a.15.04(1 m),Slats. <br /> I. Application Information-Please Print An information <br /> Property Owner's Name Parcel# <br /> .Jame.%e (�(.�Nt —IJ Ol8 - 3303 - 0 /600 <br /> Property Owner's Mailing Address Property Lavation <br /> J7 O /36 d. 6 g GovL Lot <br /> City,StateZip Code Phone Number Yy Y., Section 3 <br /> WP�1{rd wi S4$93 >/S• 866 - q{( 7 T 39 N; R /6 ff Eone} <br /> IL Type of Building(cheep all that apply) n Lot# <br /> Subdivision Name <br /> 96 or 2 Family Dwelling-Number of Bedrooms <br /> d <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use <br /> Town of <br /> IIL Type of Permit: (Check only one box on fine A. Complete tine B if applinbk) _ - _ - - - <br /> A' ❑New System ql Replacement System ❑Trestment/HoWing Tank Replacemerst Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Parmit Renewal ❑Permit Revision ❑ Change of Plumber <br /> ❑PermR Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Ow°er <br /> IV.T e of POWTS s0em/Com mtrnbDevice: Check all that a <br /> W Non-Pressurized In-Crmund ❑Pressurized In'Gmund At'Gr+de M°und>21 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑floldmg Tank ❑Other DispersalComponent(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/Ireatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdaf) Diapered Area Required(at) Dispersal Arm Proposed(sf) System El ation <br /> /J\0 o J7/Y / 9yy 9s9 q3.9 9,f• / <br /> VL Tank Wo ,Capacity in Total Fox Manufacturer u e <br /> Gallom Gallom Unita y s $ Tio New Tanks ExisngTmdmU F, }jj ry <br /> Septic er HoldvgTmdc a SO0 SOD / ..i/C.r a/ <br /> Owing Chamber <br /> VIL itesponsibih'ty Statement-L the undersigned,amume responsibility for installation of the POWTS shown W the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MFRS Number Business Phone Number <br /> Ja.rlrs tJa7/ e/s S�a �73yd0 vrs-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> d 7760 r 3S �✓ebstr. wl Sy893 <br /> VII Coun /De artotent Use(MI <br /> Permit Fee Dale issuued,{p� IssuingA gesture <br /> Approved ❑Disapproved S aJ �O �O U / <br /> ❑Owner Giver Reason for Denial ✓� <br /> IX.Conditions of Approval/Beasmn for Disapproval <br /> Arlach fo mepFete pbn for tle syateu and mb�a to the Cwnty aMy on paper not Fess dim 8 in r 11 Inehw Ind. <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />