Laserfiche WebLink
County <br /> Indust 13t^e <br /> Industry Services Division Y,44 <br /> 'ram 1400 E Washington Ave Sanitary Permit Number to be tilled in by Co.) <br /> ;' t;;:: ' '';• P.O. Box 7162 <br /> Madison,WI 53707-7162 <br /> 43747/ <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 Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary 111 7 <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Slats. <br /> I. Application Information—Please Print All Information Co Ref L <br /> Property Owner's Name C7-Parcel <br /> a�'tdy` ,s-poy--0.70"b <br /> Joe <br /> Property Owner's Mailing Address Property Location <br /> /177 Ca /Zd ie' Govt.Lot <br /> City,State r;Zip-Code Phone Number %, %, Section „�y <br /> S De►1>!►^ e/`�l cl'5e I (circle one <br /> II.Type of Building(check all that apply) Lot# T y0 N; R i'f E o(� <br /> ® 1 or2 Family Dwelling—Number ofBedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial.-Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> ® Townof Sti7' <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A• ❑New System Replacement System <br /> y �. ep y ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. El Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Data Issued <br /> Before Expiration Owner <br /> IV..T `e,of POWTS_S stem/Corn onent(Device: (Check all that apply) <br /> Rf*,` Pre inzed In-Ground ❑ Pressurized[n-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑€fa[d Tank ❑Other Oispersa]Component(explain) ❑Pretreatment Device(explain) <br /> V:c'UP al/Treatment Area Information: <br /> Des b 6*(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> yS0 5- `joo Sao 9317 .1 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 0 9 <br /> e) <br /> New Tanks Existing Tanks o u y m <br /> a U cn rn w C7 a <br /> Septic or Holding TankO <br /> Dosing Chamber_ 64G Wa j <br /> VII.Responsibility.Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumbers Name(Print) Plumber's Signature )VIP/MPRS Number Business Phone Number <br /> IZ G/lam /�✓o dU s 7�s= <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7r6o ;el.VIIl.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued [su' g ent Si e <br /> ❑Owner Given Reason for Denial -� "�'Z <br /> EX Conditions of ApprovaUReasons for Disapproval <br /> AUG -9 2021 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in 11 Inch' ®�+�D@p8Rf11Ant <br /> SBD-6393(R0313) <br />