Laserfiche WebLink
County <br /> Safety and Buildings Division <br /> 201 W.Washington Ave.,P.O.BOX 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 _ 1 9s5, <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govertunental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mail' addres <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary 03 61 �Q <br /> purposes in accordance with the Privac Law,s. 15.04 1 m),Stats. <br /> I. Application Information-Please Print All Information <br /> Pr2P9rty Owner's Name Parcel#171) <br /> 373,a <br /> Pro/perrtyy Owner's ailin A dress Property Location <br /> Govt.Lot / <br /> nZZiip C--o77d��e /Phone Nuummbberr / /,� y4, Y., Section A L (�, S CJ Z) -5-,/ /O J' 4�K T A N; R (circle one <br /> II.Type of Building(check all that apply) ?? Lot# <br /> Ch or 2 Family Dwelling-Number of Bedrooms J Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> Town of Dk <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System placement System❑Re y ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision El Change of Plumber [I Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> on-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.Dis ersal/Treatment Area Information: <br /> Design Flow((ggpd) I Design Soil Application Rate(gpdst) Dispersal Area.R aired(sf) Dispersal Area Proposed(sf) SystetrWIeyat` , <br /> Jl/ t/t?L7/ (O c/!? v Y17J�(J <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o U $ ti <br /> Now Tasks Existing Tanks V a J,:v <br /> fs.U in m to <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,a sume roWsibifity for installation of the POWTS shown on the attached plans. <br /> P mber's Name( t) Plum s Si"M <br /> MP/MPRS Number Business Phone Number <br /> um 's Address(Street City,State,Zip Code) <br /> s 6 ar <br /> V1II.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial $ • 6- 2- <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> nC_ C � COYE <br /> nD <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 z 1 1 6 size <br /> JUN 2 1 2KI IU <br /> SBD-6398(R. 11/11) -urn County <br /> Land Services Department <br />