Laserfiche WebLink
commerce.wl.gov Safety and Buildings Division County <br /> a a 201 W.Washington Ave.,P.O.Box 7162 /3(4 r n 8r <br /> sco n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be fdled in by Co.) <br /> Deparbnem of Cornmeroe 5-3Z.2 3 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wu.Adm.Code,submission of this form to the appropriate governmental 72 5-6,54 f \ 1 <br /> unit is required prior to obtaining a smarmy permit. Note: Application forme 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,a.15.04(1 m,Stab. <br /> I. Application Information-Please Print All Information J,733 law y d <br /> Property Owner's Name <br /> parcel# <br /> /{'e r z l CAn' (� Od o- 4133 3 -- e -lop <br /> Property Owner's Mailing Address C� J <br /> Property Location <br /> 7d0y '✓ 7ta St CMV trot <br /> City,State Zip Code Phone Number n�Y),�L 3 3• <br /> Y Y., Section <br /> S3. G Oct tS PAi lC /y1 Al S fy�& (circle me) ') <br /> IL Type of Building(check all that apply) Lot# T 4l6 N; R&_E 1 <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name v <br /> Block# <br /> ®I'ubadCommercisl-Describe vas srA rn tM a s' La rh)!7 <br /> ❑City of <br /> ❑State Owned-Describe UseCSM Number ❑Village of <br /> Town of 0e.le lath pf <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)(-)/7_ <br /> A. ❑New System Replacement System ❑ Treatment/Hotdin Tank oQn - _ ,. <br /> B Replacement Only ❑ Other Modification m Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ e of Plumber List Previow Permit Number and Date Issued <br /> Before Expiration G9O8 ❑Permit <br /> Trans <br /> to New <br /> Owner <br /> IV.T eo[POWTS tem/Com mt/Device: Check all that a 1 <br /> ❑Non-pressurized In-Greand Q Pressurized In-Gmuud ❑ At-Grade ❑Mound>24 in.of suitable soil ❑ Moord<24 in.of suioble soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaVrnabnmt Area Wormation: <br /> Design Flow 8-pd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 79/3 . 7 y946 9y68 4�. 7 <br /> VL Tank I1hfo Gpcity in Total #of Manufactures <br /> Gallon Gatloes Units p°, 0 8 .a <br /> C� U <br /> New Yanks Exaung Tanks C� <br /> Septic a Holding Tank -stio f Chu-d 83/.s <br /> �l Gfrr rS r v <br /> Dosing l7eaber 7S'O d /d 3 O Ora d / a t <br /> VIL Responsibility Statement-I,the undersigned,assume responsibility for installation ofthe POWTS shown ort the attached plana. <br /> Plumber's Name(PtrJint) Plumber's Signator. MP/MPRS Number Business Phone Number <br /> R/Glc hJ IC/ �J /?�s�«af.P �` �sir i >1.5,-- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> d ;; 76 o 3S 1,r s-y <br /> VIIL Coun /De artmenUse(MI <br /> Approved ❑Disapproved Permit Fec Dam Issued Ian ' at Signs <br /> 1 <br /> ❑Owner Given Reason for Denial S 3,Z5 <br /> 9P /3 Ao. 0' 9 <br /> DL Conditions of Approval/Reasons for Disapproval <br /> Attach to sanplate pares tar Poe ayann and subea t tithe Canty only an pupa not la than B urs a 1t loelaa in due <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />