Laserfiche WebLink
f v"r County <br /> /may . Safety and Buildings Division <br /> D$ r` 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Cc) <br /> \ PS.. » Madison, WI 53707-7162 <br /> Number <br /> Sanitary Permit Application Slate Transaction <br /> In accordance with SPS 383 2](2),Wis.Adm.Code.submission of this form to the appropriate governmental unit �^y y Re-View <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 secondaryb 4.� <br /> purposes in accordance with the Privacy Law,s. 15.04(1 gm),Stats. <br /> 1. Application In formation-Please Print All Information Yit etm G/< Rol <br /> Property Owner's Name L, <br /> _ Pace]#07-OA 0-,A-W-/ -t7 <br /> 'S� M 6- <br /> a,5fer TN5t 6,h,ji /S-zoo- 0/70 0 <br /> Property Owner's Mailing Address IV J Property Location <br /> J�S9O /✓p r W i /tltl itrk w.t. <br /> /7Q0 Govt.Lot <br /> City,Staten Zip Code Phone Number Section 3 <br /> Oil/L' parlL N 1SY/ "..dpiencEo© <br /> le one) <br /> K <br /> Type of Building(check all that apply) Lot# <br /> T /119 N. R o <br /> K I or 2 Family Dwell ing-Number of Bedrooms 04 Subdivision Name <br /> ❑Public/Commercial-Describe Use Block#/ rlfkr 504/r/ut50in ap ,L.oVC 2-dJLG <br /> 0 City of <br /> 0 State Owned-Describe Use CSM Number 0 Village of e <br /> Town of ©4K/d N pr <br /> 111.Type of Permit (Check only one box on line A. Complete line B if applicable) {020-9PS0- O/- '700 <br /> .A_ 0 New System Replacement System 0 Treatmem Holding Tank Replacement Only 0 Other Modification to Existing Svstem(explain) <br /> B. 0 Permit Renewal 0 Permit Revision ❑ Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IN.Type of POWTS Svstem/Com poneri ice: Check all that apply) <br /> ,N;Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound 24 in.of suitable soil 0 Mound<24 inof suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> _?o0 . 7 Ya 9 ,Iy 9/• ec <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units = — <br /> V = <br /> New Tanks flsisting Tanks v � v - <br /> V e- <br /> Septic or Holding Tank /O,S—Q /O.S p / <br /> Dosing Chamber <br /> N1 1. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber s Name(Print) Plumber s Sir!nature NIP/MPRS Number Business Phone Number <br /> 7/5- A-r7 <br /> Plumber's Address(Street,City,State.Zip Code) <br /> 7760 //, Js- /�f/ebsf f� 4v� SYS93 <br /> VIII.County/Department Gse Only <br /> Permit Fee Date Issued Issuine _ t <br /> S 3Signature <br /> Approved El Disapproved 2,251 j' <br /> ❑ Owner Given Reason for Dental <br /> 1\.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 Irz x 11 inches in size <br /> SBD-6398(R. 11/11) <br />