Laserfiche WebLink
commereeml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Sur <br /> "Wisconsin Madison,WI $3707-7162 Sanitary Permit Numbs (obs filled n by Co) <br /> eparhnerrt of Commerce C� <br /> Sanitary Permit Application Sa eTraneacUm NNumber <br /> to accordance with a.Comm.83.21(2),Wis.At.Code,submission of this form to thea appropriate governmental <br /> unit is required prior to obtaining a sanitary App PMoP <br /> submitted to the 8 person Note: Application forms for sante-owned POWTS are RojectAddress(if different than mailing address) <br /> Department of Commerce. Personal information you provide may be used for secondary <br /> sea in accordance with the Priv Law,e.15. 1)m),Stats. <br /> I. A Batian Wormation—Please Print All WOrion on 2823b .s:a�t Rd ,j5 <br /> Property Owner's Name <br /> � <br /> �f <br /> /`firs s/al Parcel#07 CA d a 14 A Zj- <br /> % �.�{-. <br /> property Owners Mailing Address (, 71 d t o o t 0}+ ma (020 4311 0170 <br /> Property Location <br /> City,State Zip Code Phone Number Govt.Lot <br /> We 6 r3 yr, y., Section 7/r- �6G- 7}JS (circle one) <br /> IL Type of Building(sdteck all that apply) Lot# T y0 N; R /,&E m(9 <br /> Pr I or 2 Family Dwelling—Number ofBedrooma y Subdivision Name <br /> ❑Public/Commercial—Dweribe Use Block# <br /> D City of <br /> D State Owned—Describe Use CSM Number ❑village of <br /> To.of '04k/q <br /> Ill.Type of Permit: (Check only one boa an Ikte A. Complete Bne B d apptipble) <br /> A. D New System Y UrReplacemrnt System ❑Treatment/Holding Tank Replacemrnt Only ❑Other Modification m Exiatia S tan <br /> 8 Ya (explain) <br /> B. ❑PEx Renewal ❑Permit Revision D Change of Plumber ❑permit Transfer to New List Previous Pmit Number and Date Issueder <br /> Beforere Expastion Ownm <br /> TV.T e of POWTS S stem/Com enf/Device: Check aU tltat a 1 <br /> .�Non-pmesur¢ed In-G-Uad O Pressurized ln-Ground D At-Cmde IlMmmd>7A io of auitable soil D Mound<24 in.of suitable soil <br /> D Holding Tank D Other Dispersal Component(explain) <br /> ❑Pretreatmrnt Device(explain) <br /> V• ersal/I'roatmatt Area Wormation: <br /> Design Flow(gpd) Design Soil Application Rate(gpdaf) Disposal Area Requved(af) Die <br /> /OD s persal Area Proposed(at) System Elevatio <br /> (� /Ot o a ant a tu 93.g 9rt, g <br /> VL To..Wo Capacity in ToW #of Manufacturer <br /> Gallons Gallons Units c <br /> New Tank. Fixiuing Tanks ' <br /> 3 it a m <br /> ' a y w c7 a <br /> Sepuc or Holding TankArc <br /> /d a vi <br /> Dating Clamber .s/G�. w X <br /> VII.Responslbibty Statement-I,the undersigned,assume responsibility far installation oflhe POWTS shown on the attached plans. <br /> Phrmber's Name(Print) Plumber's Signature� / � MP/MFRS Number Business Phone Number <br /> G- <br /> Plumber'e Address(Street,City,State,Zip Code) / y/S 7 <br /> 7760 f/r- 3S 7,tiebs71 ff/T Sh84� <br /> VI Colm /De artment Use Ont <br /> Approved ❑Disapproved permit Fee Datelssued Issuing Signa <br /> D Owns'Givrn Reason for Denis] <br /> DL Conditions of ApprovaUReasons for Disapproval <br /> Athch to eampkte plans for the syahm and whah to tk Couuly only ao pear ant lea than a trs s 11 Irchee b alae <br /> SBD-6398(R.01/07)Valid thin 01/09 <br />