Laserfiche WebLink
County <br /> Safety and Buildings Division �„7 7 <br /> A r n <br /> ;fitps � 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ' Madison,WI 53707-7162 <br /> Sanitary Permit Application State/Tr�a/n�sacti//on NuQQm��ber,, <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit «/r Y /ve-v tQ,tJ <br /> is required prior to obtaining a sanitary permit Note:Application forms for state-owned PO WTS are submitted to Project Address(ifdifferenl than mailing a�dss) <br /> /dre <br /> the Depot ment of Safely and Professional Serves. Personal information you provide may be used for secondary n1 /,„y5rh;- f'IL� <br /> purposes in accordance with the Privacy Law.s. 15.04(1)(m).Stats- Wl�l, '/ma ' <br /> 1. Application Information-Please Print.all Information 1( _ <br /> Property Owner's Name Parcel A05aoy 1.0.: OZO-4,333-0!5-&00 <br /> //­er z / CA wt P A550c. Z". �' �� l 07-020-2 40^1fo-33-5 05-003-012CCD <br /> Property Owner's Mailing Address7,20* W .27*' 5T $TE yR21(i Property Location <br /> � -733 Sfax-r- RX ..?s 6- I-ows Ag wl 55421v L �'I a wf of <br /> - <br /> ,A <br /> Zip Code Phone Number Section 33 <br /> Webs�r/ l� S$993 T N R /jcirclEore6 <br /> IL Type of Building(check all that apply) Lot# �jj <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> Public/Commercial-Describe Use CA' .00 El city of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> R Townof ©Ak7kt. <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A ❑ New System ZIReplacement System :)Treatment/Holdine 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 Dare Issued <br /> Before Expiration Owner <br /> IV.Type of POW'TS Svstem/Com onent/Device: (Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.ofsuitable soil ❑ Mound 124 in.of suitable soil <br /> 91 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(st) Dispersal Area Proposed(st) System Elevation <br /> /.l <br /> V1.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units = <br /> New Tanks Existing Tanks <br /> Septic or Holding Tank 3seQ �e10 /i(/f•«�a' )� <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POW TS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature NIP/MPRS Number Business Phone Number <br /> /7/d,/c //. /cr„ 1 /� dds9sr 7%r C66 ti/s '7 <br /> Plu%Imber's Address(Street,City,State,Zip Code) <br /> VII,L County/Department Use Onlv <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Signature <br /> L1Owner Given Reason for Denial $.375 /3 Aka WZ, <br /> A4- <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Hold'" 1`aA(( 5evues A 5 4ruV uw 44. ' may Praducc. we01GSwe6w dti/o&raar v Sod abar/� c:(I - clay <br /> A•sr�f Ra. 60AVY m4ti3 T"t /5 die oaN al'Ad"Ie &ff1VA6&4. <br /> Attach to complete plans for the system and Submit to the County only on paper not less than 8 uE x 11 inches in size <br /> SBD-6398(R.11/11) <br />