Laserfiche WebLink
Industry Services Division County <br /> `= 1400 E Washington Ave <br /> P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 5 <br /> 3 sj,3 z- <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 forts 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 3� Z Z <br /> u oses in accordance with the PrivacyLaw,s.15.04(1)(m),Stats. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name I Parcel#_4erket7 114�- 1Q I <br /> btW <br /> me <br /> Property Owner's Mailing Address Property Location iWY CPO <br /> -7?-X/ I//4 Govt.Lot <br /> City,State ! l Zip Code Phone Number <br /> Y, <br /> s,�t6?t /+ Section ln13 <br /> trcle one <br /> II.Type of Building(check all that apply) Lot# T�N; R EokW <br /> 1 or 2 Family Dwelling—Numbcr of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> V Z6" nZ A Town of 4Wi S�J <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System <br /> ys ❑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 /> Non-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.Dis ersallTreatment Area Information: <br /> Design F�(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> /7/ • 7 6yZI �y Z <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units L c w <br /> New Tanks Existing Tanks a L <br /> a U i%i y vi i.0 V a <br /> Scptic or Holding Tank <br /> UosingChantber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu cr's Name�/V" <br /> Pnt) / Pltuttber's turc MP/MPRS Number Business Pho is Numbcr <br /> T � s6�-azoZ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> �&f I Avohw I/e 4/__ (AJe6,:5 Ar Us� 55-J-7ib 9 <br /> VIII.County!De artment Use Only <br /> Approved ❑Disapproved Permit Fee <br /> Date Issued Issuing Agent Si ature <br /> ❑Owner Given Reason for Denial 3 • -1 <br /> IX.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 size <br /> MAY 3 2021 <br /> SBD-6398(R.08/14) ao <br /> �a5 - - gun y <br /> Land 9>9f'1 d" ttment <br />