Laserfiche WebLink
Commerce.wi.gov Safety and Buildings Division Cozen <br /> 201 W. Washington Ave.,P.O.Box 7162 � P ff <br /> Madison,WI 53707-7162isconsin <br /> Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce 5,3 2— 1 2 <br /> Sanitary Permit Application States Transaction Number <br /> In accordance with s.Comm.8321(2),Wis.Adm.Code,submission of this form to the appropriate governmental n-6 ku(CctJ <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POW 13 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 /> _puToses in accordance with the Privacy Law,s.15.04 1 m,Stats. Pr <br /> I. Application Information-Please Print All Inform n o�0�-3 f( �e Kked (ed <br /> Property Owner's Name �//mj�/� Parcel# <br /> K 41- es r C lama Q O ^-O G'O <br /> Property Owner's Mailing Address Property Location <br /> Govt.Lot_ <br /> City,State Zip Code Phone Number <br /> I -1 _'/, _ ., Section <br /> IQIYt K 5s 5-01 3V- aa� ircle one <br /> check a )_ <br /> II.Type of Building ll that apply) Lot# T�N; R E o <br /> IV l or 2 Family Dwelling-Number of Bedrooms_ Subdivision Name I <br /> 4 <br /> t <br /> ❑Public/Commercial-Describe Use Block# AC� <br /> ❑City of <br /> ❑State Owned-Describe Use C ElVillage of <br /> �j Town of 15 GO <br /> III.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A. P New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Pemdt Transfer to New List Prevjom Permit Number and Date Issued <br /> Before Expiration Owner L111i :3O^ <br /> IV.Type of POWTS System/Component/Device: Check all that apply) OIC <br /> KNon-Pressurized In-Ground ❑Pressurized In-Ground 0 At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of, " --so <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreannem Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flo, <br /> lo(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(s� Dispersal Area Proposed(sf) System Elevation <br /> J3 - 17 Z 9 IS-0 /, z, ` <br /> VL Tank info Capacity in Total --W—of— Manufacturer <br /> Gallons Gallons Units 9 c <br /> New Tanks Existing Tanks A Oy <br /> a V <br /> Septicor olding Tank <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigne ,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu tier's Signature MP/MPRS Number Business Phone Number <br /> IS Oe 2ZSZ21 7f3C66ee-. <br /> Number's <br /> tAddress(Street,City,State,Zip Code) T p(/_ r,, s/ir pp <br /> t S Cei Y �C✓,S V-�,� (..L),' CO 7 3 <br /> V,IIII.Count /De artment Use Onl <br /> 125 Approved E)Disapproved $ermit Fee Date Issued Issuing t Signature <br /> ❑Owner Given Reason for Denial <br /> .Nd ffl <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> SeJ N+/s 1ald(ce4< t135G - 6rdyGai»t- t�eaobya Cd..P��d• <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inches to size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />