Laserfiche WebLink
y %aa• ��,` County R <br /> Industry Services Division /emu VA eA <br /> 1400 E Washington Ave nary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 � <br /> '�, :;i`:.:'• . ,; Madison, WI 53707-7162 <br /> State Transaction Number <br /> Sanitary Permit Application <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 Project AddresAS if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary (O$�2 Y10 W�il' <br /> ID V7. <br /> purposes in accordance with the Privacy Law,s.15.04(l)(m),Slats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# j p 356 <br /> f",,14 CA0,, - <br /> Property Owner's Mailing Address Property Location <br /> '7( -16 Govt.Lot <br /> City,State Zip Code Phone Number y, y, Section 3 <br /> Cod e Grave /nN 5'.Svr b (circle one) <br /> T q/ N; P—�E or® <br /> I1.'Type of Building(check all that apply) Lot# I <br /> t or Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number Village of <br /> Town of SwtJS <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Pen-nit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.P ,.e of POWTS.S stem/Com onent(Device: (Check all that apply) <br /> �`Noq=�'ressuriaed In-Ground ❑ Pressurized In-Ground ❑ At Grade ❑ Mound>24 in.ofsuitable soil ❑ Mound<24 in.ofsuitable soil <br /> ❑ Floldm=Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V�Dis'ii al/Treatment Area Information: <br /> Desio Tl6*(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> 3aa S' (oao Gao 93.0 <br /> VI.'Tank Info Capacity in Total #of Manufacturer <br /> Y <br /> Gallons Gallons Units � P U-� <br /> Y N - <br /> New Tanks Existing Tanks o `d <br /> G 0 <br /> Septic or Holding Tank /04 0 <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 /> /Z/ae- /��® k/a S /6 S/ /S7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing gen <br /> ❑ Owner Given Reason for Denial $ 2/ Z/ <br /> n=12 0 W 1:9 R <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> MAY 14 2021 <br /> Attach to complete plans for the system and submit to the County only on paper not less than lli8fO�)}IlfCAS Department <br /> SBD-6393(R0313) <br />