Laserfiche WebLink
County <br /> Industry Services Divisionw✓/l,G' <br /> �x: '. 1400 E Washington Ave <br /> 9 Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 AJ <br /> t � Madison, WI 53707-7162 r_ <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 governmental unit /v <br /> is required prior to obtaining a sanitary pennit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary 67 yg <br /> purposes in accordance with the Privacy Law,s. 15.04(l)(m),Stats. � /) <br /> I. Application Information-Please Print All Information Co A <br /> Property Owner's Name Parcel# <br /> �1.�f�Into w �a��"ah o7 oa o-A- ya-i6'3y-.s - <br /> o.S mod <br /> a)3000 <br /> Property Owner's Mailing Address Property Location <br /> >S 6 s,S p e !9��� Sf• E Govt.Lot <br /> City,State Zip Code Phone Number y, y, Section 3 1/ <br /> t, s yy►Al J3_03.3 j(cu•cle one <br /> II.Type of Building(check all that apply) Lot# T y0 N; R /b E o� <br /> ® I or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> � Townof O&IC/and• <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System g Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Pennit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner �f�/0 7 <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> J9 HoldingTank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> f 0 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks u a <br /> y <br /> c,U <br /> O <br /> n cn <br /> I / �o � h Lt.C7 a <br /> Septic or Holding Tank C Sm 0 sed f v/es` r, x <br /> Dosing Chamber <br /> VII.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 /> /RIGIGG (Vo /G,,_r <br /> Plumber's Address(Street,City,State,Zip Code) <br /> F70 <br /> e artment Use Onl❑ Disapproved Permit Fee^ ODDate Issued Issuing Agent Signature <br /> Owner Given Reason for Denial $�7� <br /> IX.Conditions of Approval/Reasons for Disapproval E I V E <br /> A P P R UJ"h V F 0 <br /> OCT 31 2018 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t12 s i incheS ze <br /> 9 M COUNTy <br /> SBD-6393(R0313) <br />