Laserfiche WebLink
Industry Services Division County <br /> 1400 E Washington Ave <br /> I=1 S P.O.Box 7162 <br /> p5 Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> State Transaction Number <br /> Sanitary Permit Application 635�Qa <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 Address(if different than mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stars. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# Z 3 <br /> AJ <br /> Property Owner's Mailing Adddres �j� Property Location <br /> 310 "" G Govt.Lot <br /> City,State ip Code /�, Section <br /> Phone Number Y, /?f <br /> kly4lry 1 511M ',�cle on <br /> II.Type of Building check all that apply) Lot# T �� N; R _P 5 E <br /> YP g( PP Y) <br /> 1�1 or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# &e 41 <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> $r Town of �'QC *A^A <br /> 111.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 ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New 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 /> OFNon-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.DispersaVTreatment Area Information: <br /> Design Flow gpd) Design Soil A�ication Rate(gpdsf) Dispersa Are Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info , Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> E o b <br /> New Tanks Existing Tanta <br /> Scptic or Holding Tank <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Pl cr's Name(Print) Plumber's Si MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> f <br /> (f I /Tv0, i a Z le /�G/ �e�j5A, —5L/69 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑Disapproved =Denial ; <br /> t Fee Date Issued Issuing Agent Signature <br /> ❑Owner Given Reason fo �' '—Z/ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ECEOVE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 81/2 s 11 i ill <br /> JUN042021 <br /> SBD-6398(R.08/14) Bumett County <br /> 16 Land Services Department <br />