Laserfiche WebLink
s,Fcxaryasr County N ! f <br /> Industry Services Division <br /> .t Lf f. <br /> ON PbMP TJ!RlSC shington Ave Sanitary Permit Number(to be filled in by Co.) <br /> -� SPS ox 7162 <br /> '?:,\ Madison,WI 53707-7162 <br /> ,H '/i <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 <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stars. / <br /> I. Application Information-Please Print All Information -£ "�.nr f 4 R <br /> Property Owner's Name Parcel# 07-oz-9_2 'Nd -!y--1b--4! <br /> QN d �N <� f.150� 02-- oocs -Of'y�oe o <br /> Property Owner's Mailing Addre s Property Location <br /> �y w JZ > £ S£ jf <br /> a o n�✓ / C( Govt.Lot <br /> City,State Zip Code Phone Number /<, /<, Section <br /> a i'r � I t�Y6174P �/,'" J _ Z� (circle o e <br /> T }!C% N R%Y E or� <br /> Il.Type of Building(check all that apply) Lot# <br /> ® 1 or Family Dwelling-Number of Bedrooms 3 3 Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑ City of <br /> ❑ State Owned-Describe Use <br /> CSM Number El Village of <br /> L/ G ® Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. -New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS S stem/Com onent/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 /> Welding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(s[) Dispersal Area Proposed(sf) System Elevation <br /> Y ID Rate(gpdsf) I — I _ <br /> VI.Tank Info Capacity in <br /> ^ 9 <br /> Gallons Total #of m U ' .� <br /> Manufacturer <br /> Gallons Units <br /> New Tanks Existing Tanks a`V � � <br /> Septic or ding T k SJO � eLUI ❑ ❑ ❑ ❑ <br /> Dosing Chamber ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> P ber's Name(Print) Plumber's Signature MP/� Number Business Phone Number <br /> a u f t,j K,/l,S <br /> P tuber. Address(Street,City,State,Zip Code) <br /> III.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee f7 Date Issued Issuing Agent Sign re <br /> ❑ Owner Given Reason for Denial $ �7S'G/ N-4 - <br /> LX.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 x 11 inches in size <br /> SBD-6398(R03/14) <br />