Laserfiche WebLink
-- cot1 merce.Wl.gov Safety and Buildings Division County .�-y— <br /> ®�+pa 201 W. Washington Ave-,P.O. Box 7162 en <br /> /-N e, <br /> sconsin Madison,Wi53707-7162 Sanitary PermitNumber(tobefilledinbyCo.) <br /> SDISPartntem of Commerce -- 5,32 <br /> ' <br /> Sanitary Permit Application Stele"D'mnsact nen Nun her <br /> In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this fin to the appropriate e] v <br /> soemmenaal unit is required prior to obtaining s senHary permit Note: Application firms for ante-owned Project Address(if different than mailing address) <br /> POW'fS are submitted to the Department of Cumulates, Pcrxaml inlivmalion you provide may be used for <br /> secondary purposesin accordance with the privac•Law,a. 15.04(1 pn)Stats. <br /> I. AppReation Information -Please Print AN Information A,8 8 de/-j Cyd Ro a d <br /> Property Owner's Namc Parcel C 002-1632. 0/20D <br /> M4I-All, SW e, i- "-02-2-37J-SZ-I0l_- W204J <br /> Property Owner' Mailing Address Property Location <br /> City,State Lip Code INmnc Number y ip Section 3 <br /> 4 � W 3 yes 72s- y�,� �73s-. ,. ZN: R_�9 ;itr�) <br /> rtIyI.'type of Ruikling(check all that apply) Lon N <br /> Irl 1 or 2 Faouily Dwelling-Number of lednwmx Subdivision Nam <br /> Block p <br /> ❑Potblic/Commcreiel-Describe Use <br /> __--- — 11 City of—___ <br /> ❑Slate Owned-Describe Use CSM Nulwvr ❑ Village of <br /> Town <br /> IDL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> wstem A <br /> A. ❑ NcS Replacement qnlacemem5 Ysum <br /> ❑ "1'rcalmcnl/Ihnlding'tank Itcplaceeranl Only ❑Other Mwlil'aslion to Existing Syslenn(cxplain) <br /> 11. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit ltansfer to New List Previous Permit Numbernad Date Issued <br /> Before Expiration Piuml+cr Owner <br /> 1V. <br /> 'YL of I'OW'15 System/Component/Device: (Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Pwa t rizted twGromnl ❑ At-Gmde Mound >-24 in.of suitable soil ❑ Mound < 24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dixpersnl Cmnpuoecm(explain)______________ ❑14clrcmnncnl Device(captain) _ __ <br /> V. D rsnl/Treatment Area Information: <br /> Design Flow(gpd) )esign Soil len Rsle(gpdaU Disposal Am UK (at) ispceSel eryq� y/G nl(cl) Sysle evatim <br /> a <br /> Vt. Tank Info Capacity in Total N of Manufacturer <br /> Gallons Gallons Units y c y, o <br /> Now'1'ant:x lixisUMTaata <br /> Sept • IloldIgg"ane rO �)/17 w ^f- X <br /> Dosing('haenbcr AV '( n / <br /> VII. Re."ru ibility Statement - 1,The mndessigued,alntme resposadfiffity for installation of the Plows sham on the attached plans. <br /> Playm/bcr's NLannc(Print) Plmab's Sigt tore MP'/7M�RS Number Business lfionc Number <br /> /'/tolyl s/u'e r,�/t�/rd).r Gt 3 �U /1',�/7d �J <br /> (Numbers Tress(Strcat.CNY.State,Lip 4xle) <br /> V11f.County/De arhnent Use Only <br /> Approved ❑ Disapproved Permit`]Fee Date Issued <br /> r Issuing eat " lure <br /> ❑ Owner(liven Benson for tenial S I ✓V�t11� 09 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> MtaH to cutapi re phos for the V+tdn and snbmll to the C(mnsY only on paper oat las than a 1R x 11 loan Da stxe <br /> SBD-6398(R.0I/07)Valid thou 01/09 <br />