Laserfiche WebLink
eonwrtereeml.gov Safety and Buildings Division County n <br /> a 201 W.Washington Ave.,P.O.Box 7162 <br /> i seo n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department:of Commerce -5b 3(o& <br /> Sanitary Permit Application Now Ib nNunbber <br /> Adm In accordance with a.Comm.83.21(2),Wis.AdCode,submission of this form to the appropriate governments] am <br /> '/ ---F <br /> unit is required prior to obtaining a sanitary permit Note: Application forts for state-owned POWTS are Project Address(if different than mailing address) I ` 1 <br /> submitted to the Department of Commerce. Personal information you provide may be wed for secondary V I <br /> ee in accordance with the Privacy Law,a.15. 1 m),Stats. pC\ <br /> I. Applicutioa Information—Please Print Al Information WkVE. <br /> Property Owmr's Name Parcel#07-a¢o•1•go•/4.23.5 05.00/•ddOOD <br /> 7m Zirrn•fe' e Od,o 53o(3 - O SOO <br /> Property Owner's Mailing AddressProperty Location <br /> /9o,ts TPE%en wcy <br /> cm,t Lot l <br /> City,State Zip Code Phone Number 3 <br /> Y., Y., Section <br /> 4. tec v i((ie m v .5-SO g(y 41ok ?4W dW3 (circle one) <br /> IL Type of Building(check all that apply) Iut q T yD N; R /6 E or® <br /> �5`1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block p <br /> 0 Public/Commercial-Describe Use <br /> El city of <br /> 11 State Owned-Describe Use CSM Number ❑Village of <br /> V, 9 P 34 r Town of a4.e%r n il <br /> IIL Type of Permit: (Check only one boa on lite A. Complete tine B if applicable) <br /> A' yy New System ❑Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification W Existing System(explain) <br /> B. ❑Pefmit Renewal ❑Pewit Revision 0 Change ofPlmnber 0 PermitTransfer m New List Previow Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.T e of POWTS S stem/Com menVl)evice: Check a6 that apply) <br /> 9 Non-Prwsar¢ed In-Gromrd 0 Pressnrixed In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑ Moand<24 in of suitable soil <br /> 0 Holding Talc 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> =, Wnent Area Information: <br /> Design Soil Application Rate(gpdst) Dispersal Area Required(af) Dispersal Area Propwed(af) System Elevation <br /> . '7 G�43 6y8 S/• O <br /> VI.Tank Info Capacity in Total N of Manufacturer <br /> Gaaow Galtons Unita <br /> New Taub Exadmg Tanks �$ b e, p <br /> yy a d <br /> y N Xt4 ZL <br /> Septic a Holding Task &ve O <br /> dosing chamber /era / .�.�� ..� ,, <br /> VIL Responsibility Statement-1,the undersigned,mume responsibility for installation ofthe POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Rluc D kinJ 1�� e��� c1a1S�S/ �iS-6'66-5vS> <br /> Plumber's Address(Strcen,City,State,Zip Code) <br /> .)7760 /i'� <br /> VI Cotm /De artment Use Onl <br /> Approved 0 DisapprovedPermit Fas Date Issued Issuin Signature <br /> ❑Owner Given Rwon for D®ial S -i <br /> 5� ' 101 <br /> I.4.Conditions of Apprmal/Reasons far Disapproval <br /> Attach to complete plans for the system and submit to the County only m paper eol has than g In x Il imhes In dna <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />