Laserfiche WebLink
aye County <br /> Industry Services Division DtA V n-2-t <br /> ,4: � 1400 E Washington. Sanitaryy <br /> Ave <br /> Permit Number(to be ttl[ed in Co.} <br /> :— P.O. Box 7162 <br /> Madison, WI 53707-7162 <br /> CS-t'-..q <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 fortes 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 maybe used for secondary (O 3 9 1 <br /> purposes in accordance with the Privacy Law,s.15.04(i)(m),Stats. <br /> I. A lication Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> a7-coo Y�-l�-d b <br /> Jon Ha. .�e���Ka� _ 0ido00 <br /> Property Owner's Mailing Address Property Location <br /> 3lo? We( -Fay Ip 1 $Z <br /> r W <br /> Govt.Lot <br /> City,State Zip Code Phone Number y, '/<, Section ` <br /> k/t�5��, W� `$--�SA?3 (circle one) <br /> 11.Type of Building(check all that apply) 1 Lot# N; <br /> ❑ l or2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Corunercial-Describe Use <br /> ❑ City of ` <br /> ElState Owned—Describe Use CSM Number p Village of <br /> Town of kla hGR <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System El Replacement System p yY P❑Treatment/Holding Tank Replacement Only LEI Other Modification to Existing S stem(ex lain) <br /> B• 0 Permit Renewal ❑Permit Revision ❑Change of Plumber ❑PennitTransferto New t Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV..T'"e.of POVy7S".S stem/Con onent/I)evice: (Check all that apply) <br /> '0,15ra=Vp sggUrized In-Ground ❑Pressurized In-Ground ❑ At-Grade 2 Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> s_t SL �; <br /> El' <br /> ❑Other Dispersal Component(explain) ❑Pretreatment,Device(explain) <br /> WD:s" l/Treatment Area Information: <br /> Des gu^FIN(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Arg,e <br /> System Elevation <br /> 300 8 5 ° 0 VI.Tank Info Capacity in Total #of Manufactu <br /> Gallons Gallons Units v o <br /> a p; <br /> fQ U (J (_1 Q, 11 ti •� <br /> New Tanks ExisdngTanks o <br /> c U Cn m A u U G <br /> Septic or Holding Tank <br /> Dosing Chamber_ DSO!/ s� f 31 <br /> VII.Responsibility.Statement-I,the undersigned,assume responsibility for installation of the PO4VTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Addres (Street,City,State,Zip Code) <br /> VIII.Coun /De artment Use Onl <br /> Permit Fee Date Issued Issuing Agent 5ienature _ <br /> Approved ❑Disapproved f n p <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of ApprovalfReasons for Disapproval <br /> 06 W "a JUN 13 2024 <br /> mtow W �%-I� Cq1 r S he rT11W me s <br /> elax% I a6i4v446q ,vpws k,64 +30QU4r <br /> Attach to complete plans for the system and submit to the County only on paper not less thou 8 1/2 x 1 incheLpp Services Department <br /> S y25 r. e 50-'01 <br /> Qnn «no ions,,. <br />