Laserfiche WebLink
commercemi.gov Safety and Buildings Division County '7 <br /> IAhk s W.201 W. adisn.W15e,POBox7162 ,.,/_ <br /> Madison.M 53707-7162 Q rm Vol m// <br /> �epartrnem of Commerce Savitary Permit Number(to be filled m by Co.) <br /> Sanitary Permit Application StateTran--cpon Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm Code,submission of this form to the appropriate governmental <br /> unit it required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are <br /> submitted m the Depytment of Commerce. Personal information you provide ma Project Address(if different thin mailing address) <br /> ass in accordance with the Priva Law,s.]5.04(1 m),Stats. y be used for secondary <br /> I. A Bastion lnfotmation-Please print All lnfonmation <br /> Property Owner's Name "08"14' Slier G/G /4v- <br /> 671,R! <br /> el- <br /> Gre <br /> Pe fe✓Js✓1 ( Parcel# <br /> Property "'a Mailing Address 04J - JsdS� 6)s s00 <br /> at 89 �_ „$�f-4 ft, Property Location <br /> City,State GovL Lot <br /> ;� Zip Code Phare Number <br /> Sf• /G4 ( /n,)/, ss/D / Yy Yq Section01.5` <br /> bri _JJs_ 49/0 ne <br /> IL Type of Building(check all that apply) Lot# T 38 N; R /8 E(cycle oobV <br /> 1 or 2 Family Dwelling-Number ofBedrooma <br /> Subdivision Name <br /> 0 Public/Commercial-Describe Use Block# <br /> 0 Cityof <br /> 0 State Owned-Describe Use CSM Number <br /> ❑Village of <br /> 45 Town of Vl/Oap /ire Cs. <br /> A. Type of Permit: (Check only one bol on line A. Complete line B if applicable) <br /> A. <br /> , New System ❑Replacement System <br /> ❑Treatment/Holding Tank Replacement Only 0 Other Modification to ExistingS stem <br /> Y (explain) <br /> H. 0 Permit Renewal ❑Permit Revision <br /> Before Expiration El Change of ph ober 0 permit Transfer to New List Previous permit Number and Date Issued <br /> IV.T of POWTS stem/Com onent/Device: Check all that a 1 Owner <br /> 0 Non-Pmssurized In and 0 Pressurized Ia-Ground 0 At-Grade <br /> a� ❑Mound-24 in,ofsuitable soil EMound<24 in ofsuinble soil <br /> p�Holding Tank ❑Other Diapenal Component(explain) <br /> V• ersal/Treatmast Ares 0 Pretreatment Device(explain) <br /> Design Flow d �f°rotation: <br /> (Sp ) Dmign Soil Application Rate(gpdsf) Dispersal Area Requir`(at) Dispenal Area proposed(at) System Elevation <br /> 3 00 <br /> VI.Tank Into Capacity in <br /> Gallons Total #of Manafactmer <br /> T <br /> NGallons Units p <br /> aw mJrs Existing Tanks uo y b m <br /> v <br /> Septic or Holding Tank .100 <br /> elOOtl <br /> Dosing Chem6er .S/Caw X <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown an the attachedGans. <br /> Plumber's Name(Print) <br /> Plumber's Signature <br /> R/e-/� ///m MP/NURS Number Business Phone Number <br /> 1 <br /> Plumber's Address(Sttret,City,State,Zip Code) / � <br /> Iebs>�:°� c.T suers <br /> II.Cour /De artment Use Only <br /> Approved 0 DisapprovedPermit��F'e77e�� //}}���� Date Issuedsssued IssuingjA feat Signature <br /> 0 Owner(liven Reason for Demial 3`-t V' q-g7o,�? <br /> IX Conditions otApprovaUReasotm for Btsapproval <br /> Attach to complete phm for the ayamm sad mbmm to the Courtly only an paper as1 ka than a to a 11 inches b sir <br /> SBD-6398(R.01/07)Valid thm 01/09 <br />