Laserfiche WebLink
commerce.wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> is c o n s i n <br /> Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce t�fj 7bi <br /> Sanitary Permit Application State Transaction Number <br /> Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental log$ZG L I s�, <br /> unit is required prior to obtaining a sanitary permit r <br /> Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) V I <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary pp /- <br /> purposes in accordance with the Privacy Law,s.15.04 1 m,Stats. S70 © C `--- <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# 07 0/o7 yp /5-19 <br /> Stl-rA- SfI+cl - a-.5- <br /> Property Owner's Mailing Address Property Location <br /> ,,pe7 Govt. / <br /> Lot / 0 <br /> City,State Zip Code Phone Number y,, Section <br /> ircrle one <br /> T_�N; R�E W' <br /> II.Type of Building(check all that apply) Lot# <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use <br /> CSM Number <br /> ❑Village of �— <br /> rp"Townof_�Tig� Kso� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) — - <br /> A. <br /> ❑New System `.Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Compo entfDevice: Check all that apply) <br /> n-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(spill Design Soil Application Rate(gpdst) Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> sVI / S 12514 mooO 91 95% 7 S5- <br /> VI. <br /> .Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 0 v v <br /> New Tasks Existing Tanks <br /> V <br /> v � <br /> 8' � B <br /> i V rn h rn a O a <br /> Septic or Holding Tank d2.2 <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.Court /De artment Use Only <br /> Approved ❑Disapproved Pennit�Feee �j Date lls/sued Issuing a ignamrc <br /> ❑Owner Given Reason for Denial <br /> $ <br /> 32J It 16 /vl(J 10 <br /> ) <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only oa paper not lees than g In x I I inches in due <br /> SBD-6398(R.02/09)Valid thm 02/11 <br />