Laserfiche WebLink
CountyA <br /> Safety and Buildings Division U 17AW* <br /> 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> p Madison,WI 53707-7162 <br /> p <br /> S �.h` <br /> Sanitary Permit Application State Transaction <br /> Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit GO✓N�J Atte W <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),Slats. <br /> 1. Application Information—Please Print AU Information W7 Flowule Or <br /> Property Owner's Name Parcel# <br /> adOf ?"Il •j' L>x/ND <br /> Property Owner's Mailing Address Property Location <br /> 120b-0 � Govt.Lot <br /> City, tate Zip Code �Plhone Number y,, y., Section <br /> W 1 l7Qa� l -910- Z6L// N; R /Jcircle oE ow <br /> ne <br /> _:_ <br /> II.Type of Building(check all that apply) Lot# T <br /> 1 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 <br /> RJ G <br /> Townof 5'W aSS <br /> i <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. V New System Replacement System <br /> TreatmenVHolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Pertain Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: (Check all that app] ) <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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> y� 6�'8 �'�� T9zsf92v <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> U <br /> New Tanks Existing Tanks v c ¢{ P `H' R <br /> 0.V Vl ti vJ W C,7 0.. <br /> Septic or HoLding Tank /wV /coo <br /> Dosing Chamber <br /> VII.Responsibility Statement—1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plum //,be;0s Name(Print) Plum ignature MPJMPRS Numbcr Business Phone Number <br /> osg D� n�(er 8S7g5 ?i5-5t -o2oZ. <br /> Plumber's Address(Street,City,State,Zip Code)) G <br /> VIII.Coun /De artment Use Only <br /> al Approved 11 Disapproved Permit Fee Date Issued Issuing Agent Signatu <br /> ❑Owner Given Reason for Denial $ 7-5-, OD �- <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8112 x 11 inches in size <br /> SBD-6398(R. 11/11) <br />