Laserfiche WebLink
Commerceml.gov Safety and Buildings Division County <br /> 201W.Washington Ave.,P.O.Box 7162 13u r/l C-#— <br /> ,Wisconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> epartmem of Comrneroa &&83 <br /> U,J <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmemid � (� <br /> unit is required prior to obtaining a sanitary permit. Note: Application forma for state-owned POWTS are Project Address(if different than mailing address) W(�� <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary _ <br /> Purposes in accordance with the Priv Law,a.15. 1 m,Slats. 0 83y� �h r n J? n <br /> I. A Bgtion Information—Please Print All n <br /> btlinstion d• O <br /> Property Owner's Name Parcel# <br /> Steve !Y! lin j od8 f1/!9- oSSoO <br /> Property Owner's Mailing Address <br /> Property Locality <br /> 1768 Ser en-4rne lir. GwL Lot I y <br /> City,State Zip Code Phone Number <br /> Yy AILJ Yy Section /d <br /> R as ti Al �S/ot d (cock one <br /> IL Type of BLUMM9(cheek all that apply) Lot# T y0 N; R & Euro <br /> Rr I or 2 Family Dwelling—Number of Bedroom T) ZO Subdivision Name <br /> Block# <br /> ❑ <br /> Public/Commercial Coeraial—IXecribe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CS/M Numbm ❑Village of <br /> '1/ 5 UrTown of SGp <br /> IIL Type of Permit: (Check only one bus on tine A. Complete line B if applicable) <br /> New System ❑ <br /> ya Replacement System ❑Tmatment/1Iolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Rersewal ❑Permit Revision ❑ChaageofPlumber ❑Permit Tramferto New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS stem/Com onent/Devke: Cheer all that apply) <br /> K Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 is of su4abk soil ❑ Mamd<24 in,of suitable soil <br /> ❑Holdmg Tank ❑Other Disprsal Component(expbim) ❑Pretreatment Device(explain) <br /> V. ' rsavrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Requred(at) Dispersal Arty Proposed(af) System Elevation <br /> Sop S 600 <br /> dao 9.t• o <br /> VI.Tank Wo Capacity in Total #of Manufacturer <br /> Gallons Gaaam Units <br /> New Turks Existing Tanks Ff V s <br /> "sg A $9 m <br /> G <br /> Septic or Holding Tads OHO g00 .S&Aw J( <br /> Dosing Clamber <br /> VII.Rwp b(ipdty Statement-I,the undersigned,=nine responsibility for installation of the POWTS shown on the attached plana. <br /> Phsmber'e Name(Kiat) Plumber's Signature MP/M—Number Bmineea phone Number <br /> /?/c% 1t/o /cr +t / sQ �C/ ,lr8s/ lir-86d'-v/r7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7760 N� 3s tveds�e� tvr s� 8 s <br /> VI Com, /De ailment use onl <br /> Approved ❑Disapproved Pamixxt Fee �Daftued Iso❑Owmer Given Reaem fm Dermal �J�� roe <br /> DL Conditions of Appr oval/Reasom for Disapproval <br /> A Mmeasepkte ptamfordwsyabse and subseatette Cauoty onlym paperrotlest thm Sirs all laches in abs <br /> SBD-6398(R.01/07)Valid Ihru 01/09 <br />