Laserfiche WebLink
commerceml.gov Safety and Buildings Division County <br /> 201W.Washington Ave.,P.O.Box 7162 Bbt Nn E <br /> i sco n s i n Madison,W1 53707 7162 Sanitary Permit Number(to be filled in by Co <br /> Department of Commerce � e I 0 <br /> Sanitary Permit Application State Transa 1Numbeyr <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this to.to the appropriate governmental s1.0 )� cri d1 CcJ <br /> unit is required prior to obtaining a sanitary permit. NOW: Application focus 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 Roe <br /> pimposes in accordance with the Priva Law,s.15. 1)(m),Stats. 7 7( R, << /GOu <br /> I. Application Information-Please Print All InformationZatew <br /> Property Owner's Name Parcel#07-0 f 1rA " <br /> Ga-a.i L,tZ3e//e �1 a 05--903-01Toap . <br /> Prop"Owner's Mailing Address Property Location <br /> /S6/0 k'k_;—,ost, Gm2Lot -5 <br /> City,Stam Zip Code Phone Number <br /> Section 2s <br /> /4rtek4 MN 5Y703r — `'f 39 T 39 x; R r6circle one) <br /> IL Type of Building(check all that apply) Lot# yq <br /> 1 or 2 Family Dwelling-Number ofBedmoms .L Subdivision Name <br /> Block# <br /> ❑PublidCommercial-Describe Use <br /> E City of <br /> ❑State Owned-Describe UseCSMNumber ❑Village of <br /> V -I- J /7 To"of �YGaOH <br /> III.Type of Permit: (Check only one boa on line A. Complete Bute B if applicable) 5— <br /> o 00 <br /> A. stem E New System Replacement System ElTreaimrnt/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. EPevnit Renewal ❑Permit Revision EChangeofPlumber EPmmk Traruferlo New List Previous Permit Numberand Date Issued <br /> Before Expiration Owner <br /> IIV.Type of PO Sy stem/Com onent/Device: Check aft that apply) <br /> nl Non-Preasurized In-Ground E Pressurized In-Ground E At-Grade E Mound>24 in.of suitable soil E Mound<24 in.of suitable soil <br /> E Holding Tank E Other Dispersal Component(explain) E Pretreatment Device(explain) <br /> V.Di ersaVTrealment Area Wormation: <br /> Design Flow(gpd) Design Soil Applicnion Rate(gpdsf) Dispersal Area Required(af) Dispersal Area Proposed(st) System Elevation <br /> 30 0 tid <br /> V1.Tank Wo Capacity in Total #of Manufacturer <br /> Galloon Gallons Unita -1 0 <br /> New Tanles Existing Tanks „'J'o <br /> W V Ly02 <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation oflhe POWTS shown on the attached plans. <br /> .Plumb?1 Name(Print) Plumber's Signature MP/MFRS Number Business Phone Number <br /> � c/e /S�Op/�;a+t /Za-e.�.a.P �JS&S/ -7i5=864-4is7 <br /> Plumber's Addreae(Street,City,Stale,Zip Code) <br /> 7760 A11 SS PV4 6-cfrer L✓S _%'*87 3 <br /> .VaI�IIIL/L CourtTO <br /> ment Use Chill <br /> IO Approvedapproved Permit Fee Date Issued Issuing Ag lure <br /> ner Given Ramon for Denial $ <br /> 22, � k vuAf, <br /> IX.Conditions of ApprovaVRea suis for Disapproval <br /> Atbds to completr plain for the system aM eubmH to the CauNy oNy an paper not km than 8 I 111 laches in silt <br /> SBD-6398(R.01/07)Valid thin 01/09 <br />