Laserfiche WebLink
commerce.wl.gov Safety and Buildings Division County / <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> fsc o n s i n Madison,W1 53707— Permit <br /> i 7162 Sanitary PermittNumber(to be filled in by Co.) <br /> Departmem of Commerce 1.5-6 1 y rj Z W <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental i 9 8 204 1 <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS 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 Privacy Law,s.15.04 1 m,Stars. <br /> I. Application Information-Please Print All Information �U / <br /> Pro rt Owner's Name Parcel# 07 0_,n ��O �OJ <br /> Property 0 er'srMailing Address Property Location <br /> CS'n 7/ Govt.Lot 9 Q <br /> City,Stat 1/4,Zip Code Phone Number � ,_'/4, Section �l— <br /> %1J crrcleone <br /> IVm <br /> ype of Building all that Lot ply) ✓ T�N; RE/ <br /> r2 Family Dwelling-NumberofBedroos Subdivision Name <br /> -- Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of - <br /> ---- CSM Number 0 Village of <br /> ❑State Owned-Describe Use ;/// <br /> m� 'tI7Town of-, <br /> III.Type of Permit: (Check only one box on line A. Complete line B if aapplic ble) — <br /> A. 0 New System tmcmenl System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent(Device: Check all that apply) <br /> ❑Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade J"l Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow pd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(sf) Sys lem Elevation <br /> VI.Tank Info Capacity inTotal #of Manufacturer <br /> Gallons Gallons Units a c v <br /> V - <br /> New Tanks Existing Tavks <br /> a` V h h h iz t7 0. <br /> Septic or Holding Tank 199) viJ <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plana. <br /> Plumber's Name(PrintPlumber's Signature MP/MPRS Number Business Phone Number <br /> Plum is Address(Street,City,State,Zip Code) <br /> � C),-- 'Svv S . ,`^ P '-j �, <br /> VIII.Coun /De artment Use Only <br /> Approved 0 Disapproved Permit Fee Date Issued Issuing Ag nature ,t <br /> $ rav�� ,( <br /> ❑Owner Given Reason for Denial 7,5`&4 <br /> X6= <br /> ,S y{ zpf� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not leu than g In z 11 Inches to size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />