Laserfiche WebLink
Industry Savim Division gns-r--'21 <br /> 1400 E WashitOon Ave <br /> P.O.Box 7162 t Number(to bye 5 led in by Co.) <br /> Madison,W1537077162aarsdign Nu�ar <br /> Sanitary Permit Application <br /> 1 In accordance with SPS 3831)(2).Wis.Adm.Code,sbonissi«,of this form to the appropriate governmental unit <br /> is required prior to obtuang a souterY pernut Now:Application fame for staoaowred POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professiertal Services.F"Soral infmagbon you provide may be used for secondary Rps <br /> purposes in accordance with the Priv I aw s.1 S. i m Sella Z1u' 66 11v <br /> L Avorsentlas I WWAtier-Please Print All Isfot manor Parcel N Q 7 el Z-Z-yG-/5-1 c S <br /> Property Ownx's Nasrle <br /> F-JII L- I jO w_..I -� U(,W DAV!Q LIN1Dq u�tf 5 -r(LIS <br /> ProP«tr taviter's 'ling aaaress prapaty 1'0�1O1r <br /> J 117 /54" S7?PJF-67 Govt Lot <br /> City,Sate zip Code Phone Numba - 'l., 'V., Section I'� <br /> UA RRttJ L�� 6y S 1 Z 7I T y�' N; R � lcircle a l� <br /> H.Type of Building(cbe&all tkst apply) rot# Subdivision Name <br /> l or 2 Family Dwelling-Number of Bedrooms _ <br /> Block ii AJ A <br /> ❑PuMiclConmtesciai-Describe Use 0 City of <br /> ❑State Owaod-Describe Use CSM Number 0 Village of <br /> pTown of <br /> III.Type of Permit: (Cieck orty ore box or Ise A. CoMpkte the B if apptiaik) <br /> A- ❑New SysamReplacement System ❑T,,,w.rt/H"og Tank Replaeemam Only 0 Olher modification to Existing System(explain) <br /> ust <br /> B. 0 permit Renewal 0 Permit Revision 0 Change of Pitanber 0 Permit Transfer to New Aiwa Permit Number and Date Issued <br /> act"Expirationowner N <br /> IV T os Powrs S t/Device: Cheek all fiat <br /> Non-Pressurmd In- rotted ❑Pressurized In-Ground ❑At-trade ❑Mound>24 in.of ,mblc soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pmtreatnentt Device(explain) <br /> V.DbpenaVrnmilmad Area Information: <br /> Design Flaw(Wd) Design Soil Application Rn* pdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation / <br /> VI.Tank Info Capacity in TOW #of Manutactura u <br /> Gallons Gallons Units U der <br /> New Tanks Eusaeg Tanks <br /> &pticart jy 50 / UF�cT47` 1 - <br /> VII.Rea Ststtemert-1,fire made a for w ali-i gf tb.POWTS'h a e.M,atr-W ptaar. <br /> Plumber's Name(Prigs) FI 's Si I MPrbwR&N—ber Business Phan Number <br /> 110ply -T-TWK-SNII 1 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIIL Coe !Use <br /> p(�Approved 1 0 Disapproved Permit Fee Date <br /> /Issued Issuing Agmt Signature <br /> f ❑Owns Given Reason t Denial <br /> rX.Conditions of ApprevaMeasom for Disapproval <br /> Ames m ce p4sn#lo.tar tlts qst.,.nd nabrlt b the C-wq a*d pre sa ens alma a w <br /> SBD-6348 OL 08/14) T[ MO 2 5 2021 <br /> urnett County <br /> Land Services Department <br />