Laserfiche WebLink
Commerce.wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 131A 61 C7� <br /> isco n s i n Madison.WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce <br /> Sanitary Permit Application S ctim,/Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <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 use for seeondary / <br /> sea n accordance with the Privacy Law,s.15.04(1)(m),Stats. I d 8 s7$- //G I F m00 n <br /> 1. Application Information-Please Print An Information ('0 rfT <br /> Property Owner's Name Parcel H <br /> Re, Le- I Sfo" ae alre F56k&- Ee 5&46 J(wte is-; 7D- a,A9, do <br /> Property Owner's Mailing Address Property Location <br /> t 0 reto lz e ll v Govt.Lot <br /> City,State ' t Al Zip Cade Phone Number <br /> Ge/Qin V �11C mA s;yp� i T e&A1 N; R Zd Eon /� <br /> cls one), <br /> IL Type of Building(check all that apply) Lot 4 ,..ltr/f/ <br /> Xl or 2 Family Dwelling-Number of Bedrooms -3 Subdivision Name <br /> Block k } D T r1�4 <br /> ❑PublidCommercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number �❑r Villageof <br /> p Town of eJ A f/C fp h <br /> Ill.Type of Permit: (Check only one box on fine A. Complete line B if applicable) GZ_Da,. <br /> A. ❑ New S stem <br /> ry <br /> y pal Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permi[Reviaion <br /> ❑ Change of Plumber ❑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 /> XNon-Presamized In-Gruaed ❑Pressurized Lo-Ground ❑ At-Grade ❑ Mound>24 in.of suitable..it ❑ Mound<24 in.of suitable sail <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/freatmout Area Information: - <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(sf) System Elevation <br /> y.S' O -7 1 6 q3 1 6 q g, I c)l , s_ <br /> VI.Tank Into Capacity in Total #of Manufacturer <br /> Gallo. Galla. Units y E <br /> New Tank. Existing Tads ° u d9 .y <br /> Ir 0 <br /> Septic Chamber Tank /00o / /Laq b✓ X <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Sig.tme MP/MPRS Number Business Phone Number <br /> /zol c k f/v'd let- -1 /Z..fw..P A S8s' /s- 86 (•y/s` <br /> Another's Address(Street,City,State,Zip Code) <br /> 76 G 5'. 3.S` Gva6sl�t� r v s a5`�18 3 <br /> VIII.Cwut /De artment Use Ont <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing ent Signature <br /> ❑Owner Given r <br /> Reason for Denial sem/a5 <br /> IX.Conditions of Approval/Reassu s for Disapproval <br /> Attach to complete plan for the system and submit tothe County only m paper rat tem than s in it It inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />