Laserfiche WebLink
,rtrity� County <br /> '! �+ Safety and Buildings Division 3/A <br /> QS +�I 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P Madison,WI 53707-7162 � � <br /> Sanitary Permit Application State Transaction <br /> Numb r <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit G <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. <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Property Owner's Mailing Ad ss Property Location <br /> (7�+ r Y A Govt.Lot - ?� <br /> City,Star e/ Zip Code Phone Number 1/% Section Z <br /> ��jj (circle one <br /> )e­, <br /> BB/uil`dting(check all that apply) Lot# I T 7� N; R_A45 <br /> (7 <br /> E or� <br /> ❑I or 2 Family Dwelling—Number of Bedrooms it <br /> Subdivision Name lll... <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑ <br /> ❑State Owned-Describe Use CSM Number Village of Town of ®9 <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System R lacement System y �. ep y ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that app] ) 414099) <br /> Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DispersaYrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System vation <br /> 1 T47 <br /> VI.Tank Info Capacity in /J%Tototall #of Manufacturer <br /> Gallons Gallons Units yL o d <br /> New Tanks Existing Tanks o y y m <br /> d U in w rn ti U a. <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plrm <br /> s Name / Plumber' oto MPJ`MPRS Number Business Phone Number <br /> D`¢!tel Er 851 gZ) ?i$-566 <br /> Plumber's Address(Street,City,State,Zip Code) / <br /> 274?o -"aol,��lV cr We�sli^ l,.l; 5 9r <br /> Vill.Court /De artment Use Only <br /> ut Approved ❑Disapproved Permit Fee h Date Issued Issuing Agent S <br /> Owner Given Reason for Denial i ature <br /> Il $ 37,5" % <br /> ❑ <br /> tX.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 tri x I I inches in size <br /> SBD-6398(R. l 1/11) <br />