Laserfiche WebLink
County <br /> Industry Services Division �3 N r&A-el+ <br /> ,mot it R .: 1400 E Washington Ave Sanitary Permit Number(to be tilled.in.by Co.) <br /> P.O. Box 7162 h� <br /> Madison, WI 53707-7162 <br /> k tjt, <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 goveriunental unit <br /> is,required prior to obtaining a sanitary permit. Note:Application forms For state-owned POINTS are submitted to Project Address if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide maybe used for secondary d� <br /> purposes in accordance with the Privacy Law,s.15.04(l)(m),Stats. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# Lip-/y -0 9- y_6 y _da <br /> ,sfeve v1 GaU <br /> Property Owner's Mailing Address <br /> Address Property Location 7 1" <br /> ?0 13a" 3s Govt.Lot q <br /> City,State Zip Code Phone Number /, %, Section <br /> E W t^ t t ✓ h w I 5 H I� 7 �((circle ones <br /> T �V N; R /`I E or <br /> I.Type of Building(check all that apply) � Lot# <br /> I or2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial.-Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number p Village of ` �y <br /> ®Town of /ell l! <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System <br /> Re Replacement S stem p y ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. El Permit Renewal El Permit Revision El Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner �5 l 3 <br /> IV..type of POWTS..S stem/Com onent/Device: (Check all that apply) <br /> Coo P Fized In-Ground ❑Pressurized[n-Ground ❑ At-Grade ❑ blound>24 in.of suitable soil El Mound<24 in.of suitable soil <br /> — <br /> ❑Hdlam Tank ❑Other Dispersal Compoaent(explain) ❑Pretreatment Device(explain) <br /> Verb a saI/Treatment Area Information: t. <br /> De"--''dw(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sfl Dispersal Area Proposed(st) ShElovation <br /> 3 ©v 7 ti� � yso 3, S'Vl.Tank Info Capacity in Total #of Manufacturer yGallons Gallons Units o vNew Tanks ExistingTanks o `�a u w U G.Septic or Holding TankLe von <br /> Dosing Chamber_ S-0 V j 3tV1I.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POINTS shown on the attached Plumber's Name(Print)) , Plumber's Si ature NIP/MPRS Number e Numberr Gt6 He le,n sS�s/ G �y/s� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> w <br /> XApproved <br /> VIII.Coun /De artment Use Onl ElDisapproved Permit Fee Date IsssueIssuing A ent Signature❑Owner Given Reason for Denial Y� O'J 3 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> mft-- ati se+bac k-s <br /> R LLOW CO-L COLI,'I+y alto s-kk4 is I O C T 17 2023 <br /> ULP A4 cp Drlp,✓t+ ma nu_-CS 4 1►Xclur),4_ ajar Sta 1 t 011 h16+ nj <br /> Attach to complete plans For the system and submit to the County only on paper not less than 8 /:x ll.t? -%jWleces Department <br /> SB n-h194(R(l�I�1 <br />