Laserfiche WebLink
County <br /> Safety and Buildings Division AeJ me <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> SSP rl Madison,WI 53707-7162 ��/ <br /> S 'b <br /> S <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 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. I <br /> 1. Application Information-Please Print All Information 7,64 i 4/v <br /> Property Owner's Name /j� Parcel# <br /> /sN/:! Iq / d 012-Z r70•�y= _'a -��S-CtZ1 <br /> Property Owner's Mailing Address Property Location <br /> 2 #P/V A, aQ Govt.Lot 5 <br /> City,State , 1 Zip Code Phone Number y,, 14, Section <br /> 54V C/C41re w 1 J 70) 7 -7 71 ctrcicone <br /> 11.Type of Building(check all that apply) pop" ( Lot# T N; R�E o� <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of L <br /> V6 P3 WTownof f4ckspn3 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System Replacement System TrtmUHoldinB 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 qc&qq _ - 3 <br /> IV.Type of POWTS S stem/Com onent/Device: (Check all that apply) <br /> F Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑ Mound-2 N.of suitable soil <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 Proposed(sf) System Elevation <br /> %A%^ . 7 7 7 Z ti3 Z 9 q o <br /> Vt.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 16 o v cv <br /> New Tanks Existing Tanks y p U2 y a <br /> a U rn y yr ia. U a <br /> Septic or Holding Tank 0 Y <br /> eco 2 w <br /> Dosing Chamber vKKI/ l <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plum 's Name(Print) Plumbe' lallaturc MPiMPRS Number Business Phone Number <br /> 05��� Je,— ��/�� 8Sl g57 566 -0'2-0 Z. <br /> Plumber's Address(Street,City,State,Zip Code)) -/ <br /> Z 7ZZf� -J I4W,''�n/11c1 �/1��i657�F}" L-J <br /> VIII.County/Department Use Only <br /> Approved ElDisapproved Permit Fee Date Issued Issuing Agent Signa re <br /> ❑Owner Given Reason for Denial S 3 7.<, D� Q <br /> IX.Conditions of Approvat(Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 12 x 11 inches in size <br /> SBD-6398(R. 11/11) <br />