Laserfiche WebLink
eommercemi.gov Safety and Buildings Division jAdd <br /> 201 W.Washington Ave.,P.O.Box 7162 h e N <br /> 'Wisconsin e Madison,W1 53707-7162 it N b( be filled m by Co.) <br /> Sanitary Permit Application unl�Number ( 1) <br /> In accordance with a.Comm.83.21(2),Wis.Adm Code,submission of this form to the appropriate governmental �mut t reqird prior to obtaining a sanitary permit. Note: Application forms for sateowned POWTS aresubmitted to the Department of CommercePersonal information you provide may be used for secondary s(if different flanmailing address) <br /> n m accordance with theRiva Law,s.15. 1 m,Stas.1. A fixation Wormstim—PleaseprintABWormation s4*.hPropttly own"a Name <br /> R,.., John D abr/nCaq �Oa_ <br /> ••"Y1Y OWller'B Melling Address Pteperty LOGlintl <br /> 7i(� O t/G ST <br /> City,Sak =s-ela <br /> Govt Lot <br /> ' Phone Number yS Y., Section /8 <br /> ted On W1 Ie IA - 9y/- 7790 (cock one <br /> IL Type of Building(check all that apply) Lot# T 38 N; R 1`L E ore <br /> 111 or 2 Family Dwelling—Number of Bedrooms 0( ' Subdivision Nam11e <br /> Block# <br /> PobtrJCommemisl—Describe Uae <br /> 0 City of <br /> 0State Owned—Describe Use CSMNumber 0 Villageof <br /> A To.of L)we ✓60, <br /> III.Type of Permit: (Check only one boa m One A. Complete fine B M applicable) <br /> A. <br /> tet New System 0 Replacement System ❑Traatment/HoMing Tank Replacement Only ❑Other Modification to ExistingSystem <br /> (explain) <br /> B. ❑PetmitRenewal ❑Permit Revision 0 Change of Plumber List Previous Permit Number and Date Issued <br /> Before Expiration tang O mer Tramftt to New <br /> Owner <br /> rTrVy.T of POWTS tem/Com ent/Device• Check all that s <br /> Id Nen-Preseutized Tn-Ground 0 Pressurized In-Gmomd 0 At-Cmde 0 Mound>24 is of suiabk soil ❑Mound c 24 in,of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(expaa) 0 Pretreatment Device(explain) <br /> 7T=k <br /> 0ention:7;7C3Pa-ty <br /> ation Rate(gpdsf) Dispersal Area Required(sf) Di I Area Pro dpttsa poo (st) System Elevation <br /> in Taal #of Manufactuer <br /> Gallons Gallon Unit6t-- TanksSeptic or Bolding Tack7.5-0 7sv <br /> ��� SOD See <br /> VIL Besporlsibility Statement-I,the undersigned assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Rist) Pl= 'a SignaNae MP/MPRs Number Bnsineas Phone Numbtt <br /> lE isle r�o <br /> Plumber's Addnesa(Street,City,Sate,Zip Code) <br /> et 77(r o ra/.r 3s tA/B6S�a /it/1 S'Sr a 93 <br /> VIII.Cow /De artatent Use Ont <br /> Approved ❑Disappmved PermCit Fee ..IInn DDate Issued Issuing tore <br /> Owner Given Reason fm Denial a�J� % /t�o L d� <br /> IX.Conditions of APls w l/"Mmfty for Disapproval <br /> Soil MAPPED hs 6PA'IG"- d6t/A*(-A �7CN1M >C, 439 G <br /> Affuh a eaasplete planfor the syaaa and wbna lathe Caurdy lady m paper mot leas than a 1rs a 11 lmehn t sae <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />