Laserfiche WebLink
commerce.wi.gov Safety and Buildings Division County f� <br /> 201 W.Washington Ave.,P.O.Box 7162 QKMa� <br /> jf i sco n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co,) <br /> Depsrtmem of Commence Y 2290 LQ <br /> Sanitary Permit Application State Transaction Number <br /> In accordance withs.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental �✓y{ 4(./CaeJ JJ <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for stale-awned POWTS are Project Address(if different than mailing address) I �� <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary v <br /> purposes in accordance with the Privacy Law,s.15.0 1)(m),Stara. <br /> I. Application Information-please Print All Information <br /> Property Owner's Name / / Parcel#O'r 01A A 40 /Ssl 0.-0.4 <br /> 6�4VA) 5/7ArOn �/u it rs 701 0,90orb 000 5114223 a* <br /> Property Owner's Mailing Address Property Location (AL56 0/2 4723 051100) <br /> ,,k139 W- ,3,css G/c /?aGovt Lot 2. <br /> /. 4 <br /> City,State Zip Code Phone Number �rC <br /> NW %h - %y Section <br /> (circle one <br /> T 4/O N; R /.t— E o� <br /> IL Type of Building(check all that apply) Lot# <br /> ®I or 2 Family Dwelling-Number of Bedrooms 3 3 i 4 Subdivision Name <br /> Block# — 5 <br /> 11PubadCommercial-Describe Use <br /> ❑ City of <br /> El State Owned-Describe Use CSM Number 11 Village of <br /> YeLI It, 223 10Town of lfae-/&V-A <br /> IIL Type of Permit: (Check only one box on line A. Complete tine B if applicable) <br /> A. ❑ New System y [�Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> ❑Chan a ofPl tuber List Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑Permit Revision g ❑Permit Transfer[o New <br /> Before Exp Cation Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> J' Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ElMomd<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Componeat(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersabTreatment Ares Wormation: <br /> Design Flow(gpd) Design Soil Application Rate(gpdat) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> HSO , 7 647 a41F ?J.7 <br /> 4/. 7 <br /> VL Tank Wo Capacity in Total #of MamfacNrcr <br /> Gallons Gallons Units cy o <br /> New Tanks fccatme;Tanks <br /> a <br /> Septic or Holding Tank <br /> Dosing Clamber OD G0� <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plum�bbyePs Name(Print)/ Plumber's Signature MP/WRS Number Business Phone Number <br /> /CIGle- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ) 77 pD //•r., 3.s Gvtba-X-V � w.J� Sv>r!Y 3 <br /> VIU.Cam /De artment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Signature <br /> a 1 q II <br /> ❑Owner Given Reason for Denial 3n�� �3 �(Q <br /> DL Conditions of Approval/Reasons for Disapproval <br /> Will: pev6el it 4WAOA 6F Two sHeliw Pdtaalt <br /> Attach to wuplete plans for the system and anbmtt to the County only an paper rot Ira than 8 in 111 Inches In me <br /> SBD-6398(R.01/07)Valid dau 01/09 <br />