Laserfiche WebLink
tcornmerce.whgov Safety and Buildings Division Counry a.k r Its � <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> iUepm sconsin Madison,W1 53707-7162 Sanitary Permit Number(to befilledinbyCo.) <br /> ertmeof commerce State 551112 Ton Number ber U I <br /> Sanitary Permit Application _� <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental W..' 1�V)e,) <br /> unit is required prior to obtaining a sanitary permit Now: Application forms for state-owned POWTS are Proje Aijdresj If differenttltanmailing ad ress) J y� <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary a36`/ ��./]-'}%I•�e- �/ ylv�J <br /> purposes in accordance with the Privacy Law,s.15.04 1 m,Stats. <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name rParcel#o7 Oc, oZ <br /> v e, F1 J .4- 3 s /5- cfyv <br /> Property Owner's Mailing Address ( Property Location <br /> L +j,,J Pt t 14 U Govt.Lot <br /> City, late Zip Code Phone Number <br /> /Q. 1 I^ /I ) 5 A, Y.. Section <br /> //��r/'•i, - 3377 �jctrcleone <br /> 11.Type of Building(check all that apply) Lot# 7 N; R E or� <br /> �r2/// <br /> Family Dwelling-Number of Bedrooms :21 S/u�bdivision Name <br /> Block# !� (..�U -)d <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> D State Owned-Describe Use CSM Number D Village of <br /> Y�7'own of <br /> i <br /> III.Type of Permit: (Check only one box on tine A. Complete fine B if applicable) 00 — -� <br /> A. >New System ❑ Replacement System g p y g y ("plain) <br /> ❑ Treatment/Holdin Tank Replacement On] D Other Modification to Existing System(ex Iain <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type ofPOWTS S stem/Com onent/Device: Check all that apply) <br /> A,Non-Pressurized In-Ground D Pressurized In-Ground D At-Grade D Mound>24 in of suitable soil D Mound<24 in.of suitable soil <br /> D Holding Tank D Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdso Dispersal Area Required(so Dispersal Area Proposed(so Sysl Elevation <br /> a v 1 -7 �4R 9 -,;/6-0 96, 0 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 2 <br /> New Tanks Existing Tanks <br /> 0 <br /> i V y y h v. C7 a. <br /> Septic or Hatam Tank <br /> Dosing Cbamber <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 Signature MP/MPRS Number Business Phone Number <br /> /0146 <br /> Plumber's Address(Street,City,State,lip Code) <br /> Q� xsiy 7 87a <br /> VII .Coun /De artment Use Onl <br /> Approved D Disapproved Permit Fee`raj Dace Issue/d Issuing rgnature <br /> 11 Owner Given Reason for Denial E L/�J'�O 1,T44 Y 2W <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than g Vt x I I inches in size <br /> SBD-6398(R.02/09)Valid two 02/11 <br />