Laserfiche WebLink
eommeree.wl.gov Safety and Buildings Division County <br /> 201 W. Washington Ave., P.O. Box 7162 County <br /> f4" <br /> Paccordance <br /> eonsi n Madison, WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> artment of Commerce n <br /> Sanitary Permit Application State Transaction Num er <br /> s.Comm83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> rior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if differentthan mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> 5C, Slate <br /> accordance with the PrivacyLaw,s. 15.04(1 xm),Stals. <br /> ation Information-Please Print All Information <br /> ��nersi�Name p /� '/ r Parcel q <br /> UL� xA4rer/O&bwner's Mailing Address Property LocationOI-1Ico <br /> m l� comet.LolZip Code Phone Number{�[Q SW /.,-Kk/ Section (YIk v ' V (� 7/r -�9Q1 4/ circle one <br /> It.Type of Building(check all that apply) Lot M v T 7 N; R�E or 4b <br /> PP Y) <br /> I or 2 Family Dwelling-Numberof Bedrooms-- - i Subdivision Name <br /> I Block N <br /> ❑Public/Commercial-Describe Use <br /> ❑ City o1 <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> V. <br /> ""7-'1 r K-Fown of 4 4d <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, New 5 stem <br /> r+ Y El Replacement System ❑ Treatment/Fiolding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Chang a of Plumber List Previous Permit Number and Date Issued <br /> ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.T e of POWTS S stem/Com onenUDevice: (Check all that apply) <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade <br /> ❑ Mound>24 inof 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(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed is System Elevation <br /> SV 6 3 s-0 �z <br /> V1.Tank Info Capacity in Total 901 Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks V <br /> a` V rn rn aU a <br /> c Holding Tank y <br /> Dosing Chamber /` x <br /> VII. Responsibility Statement- 1,the undersigns ,assume responsibility,for installation of the Powl'S shown on the attached plans. <br /> Plum is Name(Print PI u ber's Signature MP/MPRS Numbcr Business Phone Number <br /> els Det (A C, �6- <br /> Plumber's Address(Street,City,Slate,Zip Code) <br /> 7 S Com /f :T:> tb�da , Wlr <br /> VIII Count /Department Use Only <br /> Approved ❑ Disapproved jPemilet DateIssued Issuing t Signature <br /> ❑ Owner Given Reason for Denial J� (7 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> :mach to complete plans for the system and submit to the Counry only on paper not less than a tax 11 inches in size <br />