Laserfiche WebLink
i <br /> . ., ...,7Z/„/./... <br /> ' 4 6q? V <br /> commerce.wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 �ti'\P <br /> I S CO I�s I f Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce • —� --, 51,510 -1 <br /> ‘ill E State Transaction Number <br /> Sanitary Perm' �,. pphcatio <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code, i •. r ion of this form to the appropriate g.vemamental <br /> unit is required prior to obtaining a sanitary permit i11 • �'pplicaltimm for is{cor, gowned PCWFS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal i o1,i.tion pro ide'mary be' sed,fir secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1 A • . t ti.r�,r E 2 F <br /> I. Application Information-Please Print All In orma(ion I <br /> Property Owner's Name .- 1 Parcel# <br /> 1\•t,u.a+-it d+ 4. • H111.0-1d2---- a"-70d '031 -2.0"-I G--0 <br /> Property Owner's Mailing Address Property Location <br /> c-13'71 U t Ste e Ds- Govt.Lot <br /> City,State Zip Code Phone Number Kr Vv y., N e V., Section e7 <br /> D18-0U-4-4 �� ._ (circle one)T E ar-W- <br /> I1.Type of Building(check all th ply) Lot# <br /> 4 5 Subdivision Name <br /> I or 2 Family Dwelling-N • . r of r edrooms '+ <br /> Block-0, "+'w+"w24''. - <br /> ❑Public/Commercial-Describe Use - ❑City of <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use r-� ' y <br /> od Town of n 1`-- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. [4 ew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner . <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade 12/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 <br /> (ecO (•U ((0v <br /> VI.Tank Info r Capacity in Total #of Manufacturer 0 <br /> Gallons Gallons Units -0 e' <br /> .. B <br /> V - <br /> New Tanks Existing Tanks c B P. E -8 4 -i <br /> ��,//-- a U in , h t+.C7 0• <br /> Septic orBelding-' k 1,29; 1Z`(% - I MAD X <br /> Dosing Chamber t G�� — c .) ' AC <br /> VIII.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 <br /> MP/MP RS Number Business Phone Number <br /> tkvo, tiv Md,r\k/k_ t__,'1'---a 226 c6 <br /> 03f--01c? <br /> Plumber's Address(Street,City,State,Zip Code) <br /> (,,62513 CT— - ( tom-lJL�"k_, Wt s- --7 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent S'. a-, <br /> leA <br /> PProved 0 Disapproved S 9(13.- / (�? Off) //�/�/� <br /> ❑Owner Given Reason for Denial (C! J q ____ _J v <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 5 11 inches in size - <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />