Laserfiche WebLink
ON COMPUTEMCANNED <br /> eornmerce.wl.gov Safety and Buildings DivisionCount, <br /> p 201 W.Washington Ave,P.O.Box 7162 13ti r N L tf <br /> i s4 o n s I n Madison.WI 53707-7162 Sanitary Permit Number(to be Filled in by Co.) <br /> tDepartmend of Commerce 55-1 Z)3 <br /> Sanitary Permit Application State Transaction NNumber <br /> In accordance with s.Comm.83.21(26),Wis.Adm.Code,submission of this form to the appropriate governmental CWy <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned FOWTN 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 PrivacyLaw,s.15.04(1)(m),Stats. �o /�aP /"7/ <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name - Parcel#a'7.OA O-A-40✓6••3 r/-S- <br /> je f Sm/ 'C 630 5411PA v.(6-6g- <br /> (/-) GCS <br /> Property Owner's Mailing Address/ Property Location <br /> /a 3 3 k l lA w Govt.Lot_ <br /> City,State Zip Code Phone Number ys, s/a, Section 3 y <br /> ,f4• �itwl 1J .l.f'O?/ (o S/. )1�3- 7"& itch;one) <br /> T N; R �( E or W <br /> IL Type of Building(check all that apply) Lot# <br /> PT l or 2 Family Dwelling-Number of Bedrooms `IQ�-/0 I Subdivision Name <br /> Black# C./&r5 ,� fol$ton et" Loft <br /> ❑Publie/Commercial-Describe Use N <br /> ❑ City of <br /> El State Owned-Describe Use CS Numh �4� El village of <br /> ✓ ' YJ� Townnf 61/6/4nm;Q <br /> fs <br /> III.Type of Permit: (Check only one box on line A. Complete tine B if applicable) _ <br /> A. <br /> ❑ New System �Replacement System ❑TreatmentlHoldine Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑ Permit Revision ❑ Chamo ofplumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Typse of POWTS S stem/Com onent/Device: Check all that apply) <br /> 11 Non-Pressurized In-C:somd 11pressurized In-Ground ElAt-Grade ❑Mound>24 in.of suitable soil El Mound<24 in.of suitable snit <br /> IP Bolding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersabT's"s ent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd- Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevatim <br /> z+s-0 — — — <br /> VI.Tank Info Capacity in Tocol #of Manufacturer <br /> o e <br /> Gallons Gallons Units a B o$ <br /> New Tanks Existing Tanks <br /> m c •^ m <br /> Septic or Holding l'arrk �OOjJ 3080 / J [n/ x <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation ofthe POWTS shown on the allached plans. <br /> Plumber's Name(P I) <br /> Plumber's Signature MP/MPRS Number Business Phone Number <br /> /4/C T/O /lc/nS l� dal..rIr X-1 7/S B66- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 17'60 Ny 3S 3 <br /> VIM.County/Department Use Old <br /> Approved ❑Disapproved permit Fee Grp Date Issued Issui5,,, 0K- <br /> ❑ Owner Given Reason far Denial <br /> $ „J mho , 20111 <br /> M Conditions of Approval/Reasons for Disapproval <br /> mr(5: p&W6 1 (6'j Sift. Ata✓ azjoue lf�{vikw( S"Ee AS4Far Gne/I/ 5240es <br /> Attach to complete plans for the system and suborn to the County only on paper not less than 812 a Il inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />