Laserfiche WebLink
County <br /> Safety and Buildings Division <br /> ? � 201 W.Washington Ave.,P.O.Box 7162 <br /> $P {Tj g Sani t Number(to be filled in by Co.) <br /> g � Madison,WI 53707-7162 7 <br /> t3` , 4e <br /> Sanitary Permit Application State Trans actionNumber <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 trailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> PUTOM in accordance with the Privacy Law,s.15.04(I)(m),Stats. Z <br /> L.Application Information-Please Print All Information <br /> Property 0 e 's Name Parcel# <br /> ww ? i0 6-14-5 OS-tom oZy <br /> Properly <br /> Owner's Mailing ddress - Property Location <br /> 6( veGovt.Lot <br /> City,State Zip Code Phone Number y,, 'A, Section <br /> 6q62-49-4FT 'T 0 N; R E <br /> ircle on <br /> II.Type of Building(check all that apply) Lot# <br /> o <br /> I or 2 Family Dwelling-Number of Bedrooms _ 'S Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> VP& FTown of 61 kIvtid <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, ❑ New System y ❑Replacement System WTreatmenUHolding 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 _ .(J� <br /> 1V.Type of POWTS System/Component/Device: Check all that apply) <br /> Z} <br /> KNon-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable so' <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area <br /> Proposed(sf) System Elevation <br /> S� r 7 6 G 7rj2.42-7 <br /> V1.Tank Info Capacity in Total #of Manufactorcr <br /> Gallons Gallons Units <br /> O72U <br /> New Tanks Existing Tanks w a m <br /> a U in rn is U ii <br /> Septic or Holding Tank loco <br /> Dosing Chamber WV <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached pians. <br /> Plum s Name(Print) / Plumber's MPiMPRS Number Business Phone Number <br /> ost7 857 5 -ti$-s6l�-02o Z <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Z 7ZZo �"av+�,tx„�7c/ &(el sem^ L-J; .5418 <br /> VIII.CountylDepartment Use Only <br /> Approved ❑Disapproved p nnit Fee DO Date Issued Issuing Agent Signa <br /> ❑Owner Given Reason for Denial <br /> 7s, - 7- /9•-Aa, <br /> 1X.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans far the system and submit to the County only on paper not less than 8 12 x it Inches in sin <br /> SBD-6398(R. 11/11) <br />