Laserfiche WebLink
Fn1y , <br /> Industry Services Division n t ft <br /> ! <br /> 1400 E Washin ton Ave <br /> 9 umber(to be tilled in by Co.) <br /> 10 <br /> P,O. Box 7162 �►�63 <br /> Madison, WI 53 70 7-7 1 62 j <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 / I <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Scats. �bz I�n <br /> I, Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> r tG ,sovl ©7. <br /> FriG ,>�o- -Yo-fb-.tO-SIS—yd <br /> c/y o00 <br /> Property Owner's Mailing Address Property Location <br /> 13010 ySt� �r� /�C Govt.Lot <br /> City,State �) yy, Zip Code Phone Number /, /,, Section <br /> �b/ta rvi 61 e, ("r �j fI / ',N ����I Scircle one) <br /> 11.Type of Building( eck all that apply) Lot# T y0 N; R /fO E o& <br /> V1 or2 Family Dwelling—Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑PubUc/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number fl Village of <br /> Town of Odlclschv( <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' j4New System ❑ Re Replacement S stern p y ❑Treatment/Holdino Tank Replacement Only El Other N[oditication to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑ Chancre of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.T e.of POWTS S stem/Corn onent/Device: (Check all that apply) <br /> Noa=Pied;ur-Fz in-Ground ❑ Pressurized in-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> .z <br /> x <br /> ❑ €aldui?Talk ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> VA)' ''ees'1I/Treatment Area Information: <br /> Desig O(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> yso 1 7 (K3 65-0 53. 0 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a <br /> New Tanks Existing Tanks v o a m <br /> c U cn ti ct U C? <br /> Septic or Holding Tank rj O V drj W 1 C 5 t°✓ <br /> Dosing Chamber_ <br /> VII.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 1v1P/MPRS Number Business Phone Number <br /> /��L!� �/� /c,h s /��tc..Gi�•�( /� ��,58•-mil �/S'EGG- L1�.��7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> tt.,3— <br /> VIII.County/Department Vse Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Is ent <br /> ❑ Owner Given Reason for Denial <br /> � wa�I <br /> X.Conditions of A roval aeons f r Disapproval <br /> ,'fee-{-a pp sons a� FP -?!�a� JUN 2 2 2022 <br /> 6l <br /> Burnett aunty <br /> Land r i <br /> Attach to complete plans for thesystem and submit to the County only on paper not less than 8 F_rT%Tl IncaSM ME <br /> SBD-6394 rRni i ii <br />