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titcommerce.wi.gov County <br /> li Safety and Buildings Division Dane <br /> sco f s;fl 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(filled in by Co) <br /> Department of Commerce Madison,WI 53707-7162 13-2016-00326 <br /> Sanitary Permit Application ' State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate <br /> governmental unit is required prior to obtaining a sanitary permit.Note:Application forms for state-owned ' Project Address(if different than mailing) <br /> POWTS are submitted to the Department of Commerce.Personal information you provide may be used for <br /> secondary purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> 1 Annliratinn tnfnrmatinn-PleacP Print All Infnrmatinn <br /> SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME • <br /> • <br /> V Le -i-Al'Lt f} i+C3011 4) L.-•-..•. - ❑ Zoning Status;CUP; <br /> "owNER. ••- ss(Number, -et,O r e.ZI i Deed Restriction;CAM <br /> ' l. . . , , : ! tat-S• 11 Valance(# ) <br /> H , <br /> Z' O�-3 140 CELL now E-MAIL ADDRESS <br /> C 0 Site Plan drawn to scale <br /> AGENT INFORMATION t.CONTRACTOR INFORMATION and Includes dimensions <br /> AGENT NAME . CONTRACTOR NAME <br /> 5 40e P'S PP v e 0 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> • <br /> • <br /> (cs%•ate.ble (cay,sate.zlp) • ❑ Setbacks <br /> PHONE • PHONE . • 0 Site Plan approval from <br /> applicable township: <br /> E-MAILADDRESS E-MALADDRESS 0 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:t,'accessdane.co.dane.wi.us/) 0 Elevation of property <br /> PARENT PARCEL NUMBER: tXJRRENTZ° a ACREAGE: frontage drawn to scale. <br /> 0 PARCEL ") ,C CZ- ; # i• <br /> TOWNSHIP: SECT1Oft ❑.Driveway permits <br /> \)c.•\..4 A- 11 '/4.--••--- wA. (state,county,town <br /> ADDRESS: /^� <br /> SS 5-0 001. a •6' -� TT * ' ❑Sanitary permits . <br /> CSM: LOT 2 3 - ,.. -,ION BLOCKA.OT (public,private) <br /> �.J ii'tcg-! Ito <br /> PROPOSED PROJECT INFORMATION • , . , <br /> • PROJECT DESCRIPTION: ' w,,(tj��r�1�j "I^LtC � I r .. - <br /> . CII‘is project is a new building or structure. - <br /> 0 This project is an addition/alteration to an existing building or structure. <br /> . NUMBEB: _ .—-_- .._. <br /> -- saNIT�sEWER I]SEPTIC — 1 --CO3 <br /> HEIGHT IN FEET 3 D i • NUMBER OF STORIES:I(�Ot Including base <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT 3 0 1ST FLOOR r- `,�--,3 3 psi,TOTAL SOUARE FOOTAGE: j. <br /> 2ND FLOOR] 3RD FLO V . ,-1 00 <br /> • <br /> ESTIMATED CONSTRUCTION COST. ♦ ♦ 4 ,LA OO <br /> • <br /> • <br /> (Please round to nearest dollar) � - - ,,..�.,,.// <br /> • <br /> 1. The property Is within 300 feet of a stream or 1000 feet from a pond or lake? ..... ❑Yes tif No O Don't know <br /> flvne >•In ❑Don't know <br />