Laserfiche WebLink
c,I- .w <br /> commerce.wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 D f!N <br /> is c o n s i n Madison,WI 5 3707-7 1 62 Sanitary Permit Number(to be filled in by Co.) <br /> f Department of Commerce (d /1 1 <br /> State TransaetronNumber <br /> Sanitary Permit Application <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms 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 ._ - _- <br /> purposes in 3=0 .-- + .m),Stats. r - <br /> L A . "" , formation- ' ease Print •I i • • .;on �--„, <br /> • ner's Name Parcel# .\, <br /> in aV- 4i, iibokeiv de., i1,04.31 5 0 I <br /> .. ._ Property Location <br /> 1 ct 7 D ' 1 fv . e N ` • . Govt.Lot <br /> City,State Zip Code Phone Number 5 E! vs 5W /, Section oP <br /> Co "�"ta e. C) oV��WI 535a`� `prU ,-1 -4cISO T fo N; R� F�rW <br /> IL Type of Buildincheck all that apply) Lot# <br /> fiq 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of n <br /> �Town of PleaSAAJ'- Se*0.2S6 <br /> IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System tit 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/Component/Device: (Check all that apply) 1 <br /> g Non-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(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation t <br /> 460 . LI• iIas ►■35 l'irligicq i q5, ti <br /> VI.Tank Info Capacity in Total #of Manufacturer u <br /> U <br /> Gallons Gallons Units U = <br /> New Tanks Existing Tanks `iii o .2 g . <br /> Septic or Holding Tank i 0017 i On I f 3 a M a' -a y A. <br /> Dosmeehambeler co D 0 coop I t i 1 I I <br /> - VIL Responsibility Statement-I,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 /> Timothy J Jelle 227525 <br /> • Q 608-845-7466 <br /> Plumber's Address(Street,City,State,Zip Code) yt/nN4 d� <br /> 501 Commerce Parkway Verona Wi 53593 ,' <br /> VIII.County/Department Use Only _• I <br /> Permit Fee Date sued In=.I: •t•��� <br /> roved ❑Disapproved `2, ` ��i �.- g -5,❑Own iven Reason for Denial S J- C (�}�VT �ik0' ` i�� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> •• <br /> 21311d013A30 V DNINNVId ALNA00 3NV0 <br /> Attach to complete plans for the system and submit to the County only paper not less than 8 la z 11 inches in size <br /> MAY 2 9 2007 <br /> SBD-6398(R.01/07)Valid thru 01/09 • <br /> . 03A13338 <br />