|
-------
<br /> .,..,...,4•1,7i,a7Tiegc„:.,„ County., --....
<br /> 4-,''?":?-',,, k•?`„\ Industry Services Division tit,1- Pi-e- riiv
<br /> 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.)
<br /> P.O. Box 7162 3/41422 -Q ff, Madison, WI 53707-7162 Ic>18 63/
<br /> ).-).,..,.:2;',..t,...L..... .r."
<br /> NxItic.&,:&51-e" C5-12.-137
<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 93 7
<br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats.
<br /> Ivo,v-ic- _St-
<br /> I. Application Information-Please Print All Information
<br /> Property Owner's Name Parcel#
<br /> 1
<br /> j,,, II0.7_034.A- 40-i 7-.),5-.5-os 1
<br /> -- c,
<br /> - ol7 000
<br /> Property Owner's Mailing Address Property Location
<br /> I 75, 0 ()I 3rol P4 N. Govt.Lot I
<br /> City,State Zip Code Phone Number
<br /> IA,
<br /> 'A, Section d...5—
<br /> r 1 e.p it G,u ve_ kyl/1) 3-53 I T N; R / "rclEe oonrek
<br /> IL Type of Building(check all that apply) Lot#
<br /> Z 1 or 2 Family Dwelling-Number of Bedrooms 3 1 Subdivision Name • ,
<br /> Block#
<br /> 0 Public/Commercial-Describe Use
<br /> 0 City of
<br /> CSM Number 3 7'7/7s .0 Village of
<br /> 0 State Owned-Describe Use
<br /> VA/ P67 (it Town of (-A ii/ /I
<br /> IIL Type of Permit: (Check Only one box on line A. Complete line B if applicable)
<br /> A. piti-r New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other lvfoditication to Existing System(explain)
<br /> List Previous Permit Number and Date Issued
<br /> B. 0 Pe 't Renewal 0 Pennit Revision 0 Change of Plumber 0 Permit Transfer to New
<br /> Before Expiration Owner
<br /> IV.Type Of POWTS System/Component/Device: (Check all that apply)
<br /> VTNI'aiiiRi=e`aiii-iled In-Ground 0 Pressurized ha-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil
<br /> 0'F'161djiliTairi..k 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain)
<br /> Ni' DistiVfial/Treatment Area Information: "
<br /> Des f0T1Cli,if(gpd) Design Soil Applicatio ate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation
<br /> 0.5 .• 50 0 9e a 9').5I -C. 3, -- °7 Li•
<br /> /
<br /> VI.Tank Info - apacity in Total #of Manufacturer ,
<br /> Gallons Gallons Units
<br /> New Tanks Existing Tanks t
<br /> fir.c.., a. :
<br /> Septic or Holding Tank /60, /0 0t) / k/i -c-,1
<br /> Dosing Chamber- '
<br /> VU.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 /> je/C.--/e— 0 /e/V7 /2e4// . d ,5-- ,s-/ 7/s--F4e-4-t/s-
<br /> Plumber's Address(Street, ity,State,Zip Code)
<br /> LIZ2612_82_,,,,
<br /> VIII.County/Department Use Only
<br /> Permit Fee Date Issued lssuin Agent' L,:,...r-
<br /> tirApproved 0 Disapproved
<br /> 0 Owner Given Reason for Denial $L06--- 101311-Q1 / 4/,--„C FE Jr-E '-'
<br /> IX.Conditions of 4pproval eason for Disapproval I 5 0'4, /3135
<br /> gla;id-a:di g4. ,:r seferrcko4• _ua- SEP 2 8 2022 2j
<br /> 1. 4-1Q
<br /> runcrIB8urviectet-Cs Doeupnal
<br /> Yrtment
<br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 a IL i •
<br /> SBD-6398 (R0313)
<br />
|